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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "If you let us know ahead of time that you plan to perform a procedure, we could do better job of having the supplies available." may be perceived as placing blame and does not address the immediate concern of the provider's anger.
B. "It must be very frustrating when you don't have what you need to perform the procedure." acknowledges the provider's frustration and validates their feelings, which can help de-escalate the situation and improve communication.
C. "I will help you with this procedure instead of the staff nurse." does not address the underlying issue and might not resolve the conflict or improve the situation.
D. "You should think about how you make others feel when you lose your temper." is confrontational and may escalate the situation further rather than resolving it.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. The benchmark for glucose control is 90%, but the percentages reported are consistently below this threshold: 75.29% in Quarter 1, 85.5% in Quarter 2, and 82% in Quarter 3. Improvement is needed to meet or exceed the benchmark.
B. The benchmark is 80.2%, and the percentages are above this threshold: 75.79% in Quarter 1, 80.5% in Quarter 2, and 92% in Quarter 3. No improvement needed as the measure is above the benchmark.
C. The benchmark is 85%, and the percentages reported are: 69% in Quarter 1, 85% in Quarter 2, and 86.2% in Quarter 3. Although Quarter 1 is below the benchmark, Quarter 2 and Quarter 3 meet or exceed the benchmark. Overall, the trend shows improvement.
D. The benchmark is 100%, and the percentages reported are: 90.4% in Quarter 1, 88.2% in Quarter 2, and 92.6% in Quarter 3. Although the percentages are below the benchmark, there is a trend of improvement. However, the measure still requires further enhancement to meet the benchmark.
E. The benchmark for smoking cessation education 4 weeks prior to surgery is 75%. The percentages are below this benchmark in Quarter 1 (70.6%) and Quarter 3 (74%), although it meets the benchmark in Quarter 2 (100%). Consistent adherence to the benchmark needs to be improved.
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