A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?
Assists the client to the bathroom every 2 hr
Locks the wheels on the client's bed
Raises all four side rails on the client's bed
Clears furniture from the path leading to the bathroom
The Correct Answer is C
A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.
B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.
C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.
D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. Assisting the client with relaxation techniques can be helpful in managing bladder training, but determining the client's voiding pattern is the first step in designing an effective program.
B. Incorrect. Discouraging the intake of carbonated beverages might be part of the bladder training plan, but the first step is to assess the client's current voiding pattern.
C. Incorrect. Offering toileting opportunities every 1 to 2 hours is part of the bladder training program, but determining the client's voiding pattern is the initial action.
D. Correct. The nurse should first determine the client's pattern for voiding, including the frequency of voiding and any patterns of urgency or incontinence. This information is essential to tailor the bladder training program to the client's individual needs.
Correct Answer is B
Explanation
A. Incorrect. Newborns' heads can be sensitive, and washing with a moist towelette might not be gentle enough for their delicate skin.
B. Correct. Newborns' skin is sensitive, and using a warm, wet washcloth without soap is recommended to gently clean their face.
C. Incorrect. Bathing a newborn under a running faucet can be challenging and might expose the baby to temperature variations. It's important to ensure that the baby is comfortable during bathing.
D. Incorrect. Newborns don't need to be bathed daily. Bathing them too frequently can dry out their skin and lead to discomfort.
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