A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)

Apply an ambulation alarm to the client's leg.

Obtain a prescription to restrain the client PRN.

Instruct the client in the use of the call light.

Raise all side rails on the client's bed.

Check on the client hourly.

Answer and Explanation

Correct Answer : A,C,E

Rationale:

A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.

B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.

C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.

D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.

E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.

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Correct Answer is B

Explanation

Rationale:

A. The National Council of State Boards of Nursing Decision Tree provides guidance for decision-making but does not specifically address delegation.

B. The state Nurse Practice Act defines the scope of practice for RNs and LPNs and is essential for understanding what tasks can be delegated.

C. The Omnibus Budget Reconciliation Act of 1987 primarily pertains to nursing home regulations and does not directly address task delegation.

D. The National Association for Practical Nurse Education and Services focuses on LPN education and standards, but the state Nurse Practice Act is more directly relevant to delegation.

A. AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping. B. AP 2-Verifies with nurse the order in which protective equipment should be removed. C. AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room. D. AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing. E. AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit. F. AP 4-Successfully completed skills of simulation including emptying the client's trash can

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

Explanation

A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.

B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.

C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.

D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.

E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.

F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.

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A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN?

Correct Answer is B

Explanation

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

Explanation

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