A nurse is developing a plan of care for an older adult client who has osteoporosis. Which of the following interventions to prevent falls should the nurse include in the plan?

Instruct the client to use the hallway grab bars when walking.

Assist the client to the bathroom every 4 hr.

Administer an antianxiety medication at bedtime.

Monitor the client's activity every 2 hr.

Answer and Explanation

The Correct Answer is A

A. Instruct the client to use the hallway grab bars when walking. This is correct. Using hallway grab bars provides support and stability, helping to prevent falls in clients with osteoporosis.
B. Assist the client to the bathroom every 4 hr. Assisting the client to the bathroom regularly is important, but every 4 hours might not be frequent enough and doesn't directly address fall prevention throughout all activities.
C. Administer an antianxiety medication at bedtime. Antianxiety medications can cause sedation and increase the risk of falls, especially in older adults.
D. Monitor the client's activity every 2 hr. Monitoring the client’s activity is important, but this does not provide specific fall prevention strategies or interventions.

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

Explanation

A. Place the client in contact isolation. Contact isolation helps prevent the spread of C. difficile to other patients and staff by requiring the use of gowns and gloves when entering the patient's room.
B. Prepare the client for a colonoscopy. This is not typically part of the standard care plan for C. difficile infection. Colonoscopies are not indicated for diagnosing or managing C. difficile.
C. Administer docusate sodium 500 mg daily. Docusate sodium is a stool softener and is not appropriate for treating C. difficile, which causes diarrhea.
D. Use a bleach solution to clean the client's bedside table. Bleach is effective at killing C. difficile spores, which are resistant to many other cleaning agents.
E. Use hand sanitizer immediately after caring for the client. Hand sanitizers are not effective against C. difficile spores. Handwashing with soap and water is necessary.

A. Plan to initiate a bladder retraining program for the client. B. Protect the client's perineal skin with a moisture barrier. C. Teach the client to perform pelvic floor muscle exercises. D. Request a prescription for catheter removal.

Correct Answer is D

Explanation

A. Plan to initiate a bladder retraining program for the client. This is important but not the immediate first action.
B. Protect the client's perineal skin with a moisture barrier. This is a preventive measure but not the first step in evidence-based practice.
C. Teach the client to perform pelvic floor muscle exercises. This is useful but not the immediate first action.
D. Request a prescription for catheter removal. Indwelling urinary catheters should be removed as soon as possible to reduce the risk of infection, which aligns with evidence-based practice.

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A nurse is developing a plan of care for an older adult client who has osteoporosis. Which of the following interventions to prevent falls should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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