A nurse is reviewing the plan of care for a client who is currently admitted to a medical surgical unit.
Which intervention should the nurse include to promote patient safety and prevent falls?
Keep the bed in the lowest position at all times.
Ensure the room is dimly lit during the daytime hours.
Encourage the client to walk barefoot for better grip.
Place all four side rails in the upright position.
The Correct Answer is A
Patient safety protocols require the application of fall prevention strategies and environmental management. Knowledge of hospital safety standards, mobility mechanics, and the legal implications of restraints is necessary to select interventions that minimize injury risks while maintaining a safe therapeutic environment.
Choice A rationale
Keeping the bed in the lowest position minimizes the vertical distance to the floor, significantly reducing the impact force and potential for injury if a client attempts to exit the bed unassisted. This is a primary fall prevention standard.
Choice B rationale
Dim lighting during daytime hours decreases visual acuity and increases the risk of environmental trips or missteps. Adequate illumination is required for clients to identify obstacles, perceive depth accurately, and navigate their surroundings safely during active hours.
Choice C rationale
Barefoot walking increases the risk of slipping on smooth hospital floor surfaces. Safety protocols mandate non-skid footwear or socks with rubber grips to provide necessary traction and stability, preventing falls related to a lack of foot-to-floor friction.
Choice D rationale
Raising all four side rails is classified as a physical restraint in many jurisdictions and can actually increase injury severity. Clients may attempt to climb over the rails, leading to falls from a much greater height.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Monitoring critical illness requires understanding hemodynamic monitoring through invasive catheters. Knowledge of cardiovascular physiology and the specific capabilities of the Swan-Ganz catheter is necessary to distinguish between parameters that are directly measured versus those calculated via mathematical hemodynamic formulas.
Choice A rationale
Pulmonary artery catheters do not measure mean arterial pressure, which requires a peripheral arterial line. PAP and CO are measured, but the inclusion of MAP makes this choice incorrect as it assesses systemic rather than pulmonary hemodynamics.
Choice B rationale
This catheter sits in the pulmonary artery, allowing direct measurement of systolic, diastolic, and mean PAP. Inflation of the balloon allows measurement of PAWP, while thermistor technology enables the direct calculation of cardiac output via thermodilation.
Choice C rationale
Central venous pressure is measured via the proximal port of the catheter, but MAP and SVR are not direct measurements. SVR is a calculated value derived from MAP, CVP, and CO using a mathematical formula.
Choice D rationale
While cardiac output is measured directly, stroke volume and systemic vascular resistance are calculated parameters. Stroke volume is determined by dividing cardiac output by heart rate, while SVR utilizes the pressure gradient across the systemic circuit.
Correct Answer is A
Explanation
Dexamethasone is a potent corticosteroid used to reduce cerebral edema in brain tumor patients. Prioritizing care requires identifying life-threatening neurological changes or severe medication side effects, applying knowledge of intracranial pressure, glucose metabolism, and the hierarchy of clinical needs.
Choice A rationale
Acute loss of orientation to self indicates a significant decline in neurological status or increased intracranial pressure. This is a medical emergency requiring immediate intervention to prevent brain herniation, outweighing stable physical side effects of steroid therapy.
Choice B rationale
Weight gain is a common side effect of long-term dexamethasone use due to fluid retention and increased appetite. While it requires monitoring, it is an expected systemic effect and does not represent an immediate life-threatening crisis.
Choice C rationale
Insomnia is a known side effect of corticosteroids because they can interfere with the circadian rhythm and stimulate the central nervous system. It affects the client's comfort but does not indicate immediate physiological or neurological compromise.
Choice D rationale
Glucocorticoids cause hyperglycemia; 350 mg/dL is high compared to the normal fasting range of 70 to 100 mg/dL. While it requires insulin or dosage adjustment, it is less urgent than an acute neurological deficit..
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