A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

Place the bedside table within the client's reach.

Teach balance and strengthening exercises.

Provide information about home safety checks.

Administer sedative at bedtime.

Lock beds and wheelchairs when not providing care.

Answer and Explanation

Correct Answer : A,B,C,E

A) Place the bedside table within the client's reach: This is an important safety measure to help prevent falls. By ensuring that the bedside table is within easy reach, the client will be less likely to try to reach for objects outside their immediate area, reducing the risk of falls from overextending or getting up unnecessarily.

B) Teach balance and strengthening exercises: Teaching balance and strengthening exercises is a key preventative measure for older adults at risk for falls. These exercises help improve muscle strength, coordination, and stability, which can significantly reduce the likelihood of falls.

C) Provide information about home safety checks: Providing information about home safety is essential to prevent falls in older adults. This includes advising the patient on eliminating hazards (like loose rugs, clutter, or inadequate lighting) and ensuring that the home environment is conducive to safety. A home safety check is part of creating a fall-prevention strategy.

D) Administer sedative at bedtime: Administering sedatives to older adults, especially those at risk for falls, can increase the likelihood of confusion, dizziness, or impaired coordination, which can lead to falls. This is not a recommended intervention. Non-pharmacologic methods for improving sleep hygiene should be prioritized over sedative medications when possible.

E) Lock beds and wheelchairs when not providing care: Locking beds and wheelchairs when not in use is a fundamental safety measure to prevent accidental movement of the bed or wheelchair. This action reduces the risk of the patient falling out of bed or from a wheelchair if they try to move or shift positions.

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Correct Answer is A

Explanation

A) Have the client wear a mask: This is the appropriate action to take. When transporting a client with active pulmonary tuberculosis, the client should wear a mask to help prevent the spread of airborne pathogens. This is especially important when leaving the isolation room, as it minimizes the risk of contaminating the environment and others in public areas like hallways or the radiology department.

B) Notify the x-ray department that the client requires airborne precautions: While it is important to notify the x-ray department about the patient's airborne precautions, this alone is not sufficient for ensuring safe transport. Airborne precautions require the client to wear a mask, and the nurse should take additional precautions as well.

C) Wear a filtration mask and gloves during transport: While the nurse should wear appropriate personal protective equipment (PPE), including an N95 respirator (filtration mask) when in close contact with the client, the focus of the question is on ensuring the client’s safety during transport. The primary precaution for the client to take is wearing a mask.

D) The client's room to obtain a portable x-ray: This would be a safe alternative to transporting the client if a portable x-ray machine is available. However, in the case that transport to the radiology department is necessary, wearing a mask is the key precaution to prevent the spread of TB. The question specifically asks about the transport process, not about the use of portable x-ray equipment.

A. Try to do as much as possible for the patient. B. Encourage dairy products. C. Monitor intake of calcium D. increase intake of caffeinated drinks.

Correct Answer is C

Explanation

A) Try to do as much as possible for the patient:
While it's important to provide support to a patient with osteoporosis, especially when they are at risk of fractures, the nurse should focus on empowering the patient to maintain as much independence as possible. Over-involvement in their care may limit their ability to maintain or improve mobility and self-care abilities. The priority is addressing nutritional needs and bone health.

B) Encourage dairy products:
While dairy products are an excellent source of calcium, this approach is not suitable for a patient with lactose intolerance. Consuming dairy could lead to discomfort and digestive issues such as bloating, cramps, and diarrhea, which can worsen the patient's symptoms. Alternative sources of calcium should be recommended instead.

C) Monitor intake of calcium:
This is the most appropriate intervention. Monitoring the patient's calcium intake is crucial for individuals with osteoporosis to help strengthen bones and prevent fractures. The nurse can recommend calcium-rich foods that are lactose-free, such as fortified plant-based milks, leafy green vegetables, and fortified cereals. Calcium supplements may also be necessary to meet the daily requirements.

D) Increase intake of caffeinated drinks:
Increasing caffeinated drinks is not advisable for a patient with osteoporosis, as excessive caffeine consumption can interfere with calcium absorption and contribute to bone loss. It is best to limit caffeine intake and focus on promoting good nutritional habits to support bone health.

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A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

Correct Answer is A

Explanation

A nurse is caring for a patient diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement

Correct Answer is C

Explanation

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