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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Desired dose = 50 mcg
Available strength = 0.025 mg/tablet
- Convert desired dose to milligrams (mg):
1 mg = 1000 mcg
50 mcg / 1000 mcg/mg = 0.05 mg
- Calculate the number of tablets:
Number of tablets = Desired dose (mg) / Available strength (mg/tablet)
= 0.05 mg / 0.025 mg/tablet
= 2 tablets
Correct Answer is C
Explanation
A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.
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