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A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)

Ensure the client wears nonskid slippers when walking around the house.

Attach full-length side rails to the client's bed.

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

Encourage an annual review of the medications the client is taking.

Place throw rugs on uncarpeted floors in the client's home.

Answer and Explanation

Correct Answer : A,C,D

Ensure the client wears nonskid slippers when walking around the house.

Explanation: Nonskid slippers provide better traction and stability, reducing the risk of slipping.

B.Attach full-length side rails to the client's bed.

Explanation: Side rails can pose a risk of entrapment and may not prevent falls. The use of side rails is associated with safety concerns, and their use should be carefully evaluated.

C.Install a raised toilet seat in the client's bathroom.

Explanation: A raised toilet seat makes it easier for the client to sit down and stand up, reducing the risk of falls in the bathroom.

D.Encourage an annual review of the medications the client is taking.

Explanation: Medication reviews help identify drugs that may increase the risk of falls or interactions that could affect balance or cognitive function.

E.Place throw rugs on uncarpeted floors in the client's home.

Explanation: Throw rugs can be tripping hazards, especially for older adults with mobility issues. It's safer to have clear, unobstructed pathways in the home.

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Correct Answer is A

Explanation

A. Shake the suspension well before each administration.

The medication label specifically states, "IMPORTANT: SHAKE WELL BEFORE EACH USE," and "THIS PRODUCT MUST BE SHAKEN WELL ESPECIALLY PRIOR TO INITIAL USE." This indicates the necessity of shaking the suspension before administration to ensure proper mixing of the medication.

B. Dilute the suspension with 38 mL water prior to initial use.

There is no indication on the label to dilute the suspension with water. The label emphasizes shaking well before use, but dilution is not mentioned.

C. Store the suspension in the refrigerator.

The storage instructions on the label state, "Store at 20° to 25°C (68° to 77° F) see USP controlled room temperature." Refrigeration is not mentioned, and it is not recommended to deviate from the specified storage conditions.

D. Discard the suspension 14 days after opening the bottle.

The label does not provide specific information about the shelf life after opening. Therefore, it is essential to follow the specific instructions on the label or refer to the package insert for complete prescribing information regarding the expiration or discard date after opening. The information on the label does not specify a 14-day limit.

A. Inserting a straight urinary catheter for a client B. Performing perineal care for a client who has an indwelling urinary catheter C. Showing a client how to use an incentive spirometer D. Increasing oxygen flow for a client who has a nasal cannula

Correct Answer is B

Explanation

A. Inserting a straight urinary catheter for a client:

Inserting a urinary catheter involves a sterile procedure and requires the specialized skills of a licensed nurse. This task should not be delegated to assistive personnel.

B. Performing perineal care for a client who has an indwelling urinary catheter.

Delegating tasks should align with the education, training, and scope of practice of the assistive personnel. Performing perineal care for a client with an indwelling urinary catheter is a task that can be appropriately delegated to assistive personnel. This task involves basic hygiene and does not require the advanced skills or knowledge of a licensed nurse.

C. Showing a client how to use an incentive spirometer:

Educational tasks, such as demonstrating how to use an incentive spirometer, require knowledge and understanding of the device, as well as the ability to assess and respond to the client's needs. This task is best performed by a licensed nurse.

D. Increasing oxygen flow for a client who has a nasal cannula:

Adjusting oxygen flow involves assessing the client's condition and making decisions based on the client's oxygenation needs. This task requires the clinical judgment of a licensed nurse and should not be delegated to assistive personnel.

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A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phenytoin oral suspension to a client. Which of the following actions should the nurse take? (Refer to the medication label below.

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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