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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Correct. Chadwick's sign is a bluish or purplish discoloration of the vaginal and vulvar tissues due to increased vascularity that occurs during pregnancy. This is a normal finding in early pregnancy.
B. Incorrect. Chloasma refers to the appearance of dark patches on the skin, often seen on the face, and is not related to the vaginal and vulvar color changes seen in Chadwick's sign.
C. Incorrect. Hegar's sign refers to the softening of the cervix and isthmus of the uterus, not the color changes in the vaginal and vulvar tissues.
D. Incorrect. Ballottement is a physical examination technique used to assess a floating mass in the body, such as a fetus, and is not related to the color changes in the vaginal and vulvar tissues.

A. Wear shoes with rubber soles. B. Conduct change of shift reports near the clients' rooms. C. Open curtains between clients in semi-private rooms. D. Turn on overhead lights briefly when checking IV lines.

Correct Answer is A

Explanation

The correct answer is choice a. Wear shoes with rubber soles.

Choice A rationale:

Wear shoes with rubber soles () - Quiet footwear minimizes noise disruption during sleep hours, promoting a better sleep environment.

Choice B rationale:

Conduct change of shift reports near the clients’ rooms () - Conducting reports near rooms creates noise and disrupts sleep. It’s best done in designated areas away from patients.

Choice C rationale:

Open curtains between clients in semi-private rooms () - Privacy and individual light control are crucial for sleep. Open curtains can disrupt a client’s sleep cycle.

Choice D rationale:

Turn on overhead lights briefly when checking IV lines () - Bright lights suppress melatonin production, a hormone vital for sleep. Using alternative light sources or dimmed lighting minimizes sleep disruption.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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