A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

Silence the bed alarm when visitors are at the client's bedside.

Establish an elimination schedule for the client.

Raise all four bed rails on the client's bed.

Allow the client to walk unassisted near the nursing station

Answer and Explanation

The Correct Answer is B

A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.

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Correct Answer is ["B","C","D"]

Explanation

A. "Blurred vision is an expected adverse effect of this medication." Blurred vision is not a common or expected adverse effect of lithium. If this occurs, it may indicate toxicity or another underlying issue and should be reported. It is not part of routine education for expected side effects.
B. "This medication can cause weight gain." This is true. Weight gain is a known long-term adverse effect of lithium therapy and should be discussed with the client and family as part of monitoring and lifestyle considerations during treatment.
C. "This medication can cause nausea and drowsiness." These are common initial side effects when starting lithium and usually subside over time. Clients should be aware of these effects so they can differentiate between expected reactions and signs of toxicity.
D. "It will take at least a week before this medication reaches a therapeutic level." Correct. Lithium takes 7–14 days to reach therapeutic plasma levels, so clients may not experience symptom relief immediately. During this period, supportive care and safety monitoring are essential.
E. "You will be placed on a low-sodium diet while taking this medication." This is incorrect. Lithium has a narrow therapeutic index, and sodium levels affect lithium levels. A low-sodium diet can increase the risk of lithium toxicity, so clients should maintain a consistent sodium intake, not reduce it.

A. Palms of the hands B. Area of trauma C. Sacrum D. Shoulders

Correct Answer is A

Explanation

A. Palms of the hands. In clients with dark skin, assessing for cyanosis is best done in areas where skin is lighter and blood vessels are more visible, such as the palms, soles, lips, mucous membranes, and conjunctiva. These sites provide clearer visual cues of decreased oxygenation.
B. Area of trauma. This area may show signs of bruising or inflammation, but it is not ideal for assessing cyanosis. Local changes in color may be due to injury, not systemic oxygenation.
C. Sacrum. The sacrum is typically assessed for pressure injuries, not for cyanosis. Its location and frequent pressure make it a less reliable site for detecting systemic color changes.
D. Shoulders. The shoulders are not reliable sites for detecting cyanosis, especially in individuals with darker skin, as color changes may be less apparent in more heavily pigmented or sun-exposed areas.

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A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.

Correct Answer is ["B","C","D"]

Explanation

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?

Correct Answer is A

Explanation

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