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.

Allow the client to walk unassisted near the nursing station.

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

Answer and Explanation

The Correct Answer is B

A. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm compromises safety by preventing timely notification if the client attempts to get out of bed unassisted. Bed alarms should remain active at all times for clients on fall precautions.

B. Establish an elimination schedule for the client: Scheduling regular toileting reduces the risk of falls by minimizing unassisted trips to the bathroom, which are a common cause of falls, especially in clients with mobility or cognitive impairments. This is an effective and preventive intervention.

C. Allow the client to walk unassisted near the nursing station: Clients on fall precautions should not ambulate without assistance or appropriate safety measures, even near the nursing station, as unassisted walking increases the risk of falls.

D. Raise all four bed rails on the client's bed: Raising all four bed rails can increase the risk of injury if the client attempts to climb over them and is generally considered a restraint, which requires careful assessment and provider authorization.

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

Explanation

A. Obtain a provider order for vaginal/anal culture: A vaginal or anal culture is not indicated at this time because the client’s symptoms—dysuria, urinary frequency, and positive leukocyte esterase—are consistent with a urinary tract infection rather than a sexually transmitted infection or perianal infection.

B. Obtain a provider prescription for antibiotics: The client demonstrates signs of a urinary tract infection, including dysuria, positive leukocyte esterase, elevated WBC count, and cloudy urine. Prompt initiation of antibiotics is important in pregnancy to prevent complications such as pyelonephritis and preterm labor.

C. Obtain a provider prescription for ibuprofen 600 mg every 6 hr for mild to moderate pain: Ibuprofen is generally avoided during the third trimester because it can cause premature closure of the fetal ductus arteriosus and oligohydramnios. Alternative analgesics that are safe in pregnancy should be used instead.

D. Obtain a provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can help relieve dysuria and urinary discomfort while the client awaits antibiotic therapy. It does not treat the infection itself but improves client comfort.

E. Obtain a provider order for a urine culture: A urine culture is indicated to confirm the presence of infection and identify the causative organism. This ensures that antibiotic therapy can be tailored appropriately, which is especially important in pregnancy to reduce maternal and fetal complications.

A. Headache B. Numbness and tingling of the extremities C. Increased salivation D. Sensation of skin warmth

Correct Answer is D

Explanation

A. Headache: Headache is not an expected finding during cardiac catheterization. If it occurs, it may indicate an unrelated issue such as anxiety, dehydration, or reaction to contrast dye, but it is not typical of the procedure itself.

B. Numbness and tingling of the extremities: Numbness and tingling are not expected during cardiac catheterization. These symptoms could suggest a complication such as nerve compression, impaired circulation, or allergic reaction, requiring immediate evaluation.

C. Increased salivation: Increased salivation is not associated with cardiac catheterization. This finding may be linked to oral stimulation or nausea, but it is not a normal response to the procedure.

D. Sensation of skin warmth: Clients often report a sensation of warmth or flushing during the injection of contrast dye used in cardiac catheterization. This response is expected and temporary, resulting from vasodilation and the chemical properties of the contrast medium.

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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 continues to care for the client. Which of the following actions should the nurse take? Select all that apply.

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

Explanation

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Correct Answer is D

Explanation

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