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 D

Explanation

A. Hold the dropper just inside the ear canal. The dropper should be held above the ear canal to avoid contamination and injury.
B. Apply sterile gloves prior to administration. Sterile gloves are not necessary for administering ear drops. Clean gloves are sufficient.
C. Have the client remain in a side-lying position for 10 min. This is unnecessary. The client can return to an upright position after the medication has been administered.
D. Pull the pinna up and back. This is correct for adults. Pulling the pinna up and back straightens the ear canal for proper medication administration.

A. Keep the collection bag below the level of the bladder. B. Irrigate the catheter routinely with sterile water every other day. C. Use an antiseptic to cleanse the periurethral area twice each day. D. Disconnect the catheter from the drainage tubing to collect urine specimens.

Correct Answer is A

Explanation

A. Keep the collection bag below the level of the bladder. This prevents backflow of urine, which can introduce bacteria into the bladder and cause infection.
B. Irrigate the catheter routinely with sterile water every other day. Routine irrigation is not recommended as it can introduce pathogens and increase the risk of infection.
C. Use an antiseptic to cleanse the periurethral area twice each day. Cleansing with soap and water is recommended; frequent antiseptic use can irritate the skin and is not necessary.
D. Disconnect the catheter from the drainage tubing to collect urine specimens. Disconnecting the catheter can introduce bacteria and increase the risk of infection. Specimens should be collected using a sterile technique without disconnecting the system.

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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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