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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The occiput refers to the back of the head. Placing a small pillow or padding under the occiput can help relieve pressure and provide support to the client's head and neck when they are placed in the supine position.
Breasts: When in the prone position, breasts may be compressed or flattened. To relieve pressure, it may be necessary to use positioning techniques that distribute weight evenly and avoid direct pressure on the breasts, such as using cushions or foam pads to support the chest and torso.
Heels: The heels are prone to pressure ulcers when a client is lying in the supine position for extended periods. To relieve pressure, it is important to use proper heel offloading techniques, such as placing heel protectors or pillows under the lower legs to elevate the heels off the bed surface and prevent direct pressure.
Coccyx: The coccyx is the tailbone region at the base of the spine. When in the supine position, pressure on the coccyx can be relieved by using a cushion or padding under the pelvic area, specifically under the bony prominence of the coccyx, to reduce direct pressure and provide comfort.
Correct Answer is C
Explanation
A. Allowing a family member to stay with the body is a common practice in many cultures, but it is not specific to Islamic practices.
B. Positioning the head northward is not a specific requirement of Islamic postmortem care.
C. Correct. Positioning the client's head toward Mecca is an important aspect of Islamic postmortem care, as Muslims pray facing Mecca.
D. Allowing a family member to stay with the body for a specific duration is not a specific Islamic practice.
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