A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

Install a bed exit sensor pad at the foot of the client's bed.

Encourage the client to ambulate in compression stockings.

Raise all four side rails for the client at bedtime.

Place a raised toilet seat in the client's bathroom.

Answer and Explanation

The Correct Answer is D

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Cleanse the urethral meatus. This step occurs after preparing the sterile field and donning sterile gloves.
B. Apply sterile gloves. This is correct. The first step in the standardized procedure is to apply sterile gloves to maintain aseptic technique throughout the catheter insertion process.
C. Attach the pre-filled syringe to the inflation bulb. This step is part of the preparation but comes after the sterile gloves are applied.
D. Saturate the cotton balls with antiseptic. This step occurs after donning sterile gloves.

A. Ginkgo biloba B. Feverfew C. Echinacea D. Melatonin

Correct Answer is D

Explanation

A. Ginkgo biloba is often used to improve cognitive function and memory, not for sleep.
B. Feverfew is commonly used to prevent migraines and not typically for insomnia.
C. Echinacea is primarily used to boost the immune system and treat colds, not for sleep.
D. Melatonin: This is correct. Melatonin is a hormone that regulates sleep-wake cycles and is commonly used as a supplement to treat insomnia.

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Nursing Test Bank

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