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. Asking other staff nurses does not address the immediate concern of the client and could lead to gossip or unnecessary complications.

B. Addressing the concern with the specific staff nurse directly is appropriate to understand any issues and to see if there is a valid reason for the client’s request.

C. Recommending transfer without understanding the issue could be premature and might not address the root of the problem.

D. Notifying human resources is a step that may be needed later but should not be the first action; the manager should first address the issue with the staff nurse.

A. Agency policies for the LPN B. The documented experience level of the LPN C. The documented skill level of the LPN D. State Nurse Practice Act for the LPN

Correct Answer is D

Explanation

Rationale:

A. Agency policies for the LPN are important but secondary to ensuring the tasks fall within the scope of practice.

B. The documented experience level of the LPN is relevant but should be considered in conjunction with the scope of practice.

C. The documented skill level of the LPN is important for assigning tasks but must align with legal scope of practice.

D. State Nurse Practice Act for the LPN is the priority criterion as it defines the legal scope of practice and ensures that tasks delegated to the LPN are within their legal and professional boundaries.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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