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 A

Explanation

Rationale:

A. Encouraging clients to receive an annual flu immunization is a cost-effective measure to prevent illness and reduce overall healthcare costs.

B. Waiting to empty a drainable colostomy until it is three-fourths full might not be the best practice for client comfort or prevention of leakage.

C. Recommending sterile technique for home care is important for infection prevention but not necessarily a cost-reduction strategy in the healthcare setting.

D. Delegating closed irrigation to AP may not be appropriate if it involves tasks beyond their scope of practice and does not directly relate to cost reduction.

A. Teach a client about low-sodium foods. B. Measure and record intake and output for a client. C. Perform wound irrigation for a client. D. Evaluate pain relief for a client following the administration of a pain medication.

Correct Answer is B

Explanation

Rationale:

A. Teaching about low-sodium foods requires specialized knowledge and should be performed by an RN.

B. Measuring and recording intake and output can be done by an AP, as it involves routine data collection rather than clinical judgment.

C. Wound irrigation is a more complex procedure that requires clinical skills and should be performed by an RN or LPN.

D. Evaluating pain relief involves clinical assessment and judgment, which is beyond the scope of an AP.

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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

A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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