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
Raises all four side-rails on the client's bed
Locks the wheels on the client's bed
Clears furniture from the path leading to the bathroom
The Correct Answer is B
The correct answer is B. Raising all four side-rails on the client's bed is considered a restraint and can increase the risk of injury if the client tries to climb over them. The nurse should intervene and instruct the AP to lower one or two side-rails and use other fall prevention measures, such as bed alarms, nonskid footwear, and frequent checks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The AP pulls the pinna up and back.
Choice A rationale:
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
Choice B rationale:
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
Choice C rationale:
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
Choice D rationale:
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.
Correct Answer is B
Explanation
The correct answer is choice b. I will need to remain upright for 1 hour after taking the medication.
Choice A rationale:
Pantoprazole can be taken with or without food, so it does not need to be taken on an empty stomach.
Choice B rationale:
Remaining upright for at least 1 hour after taking pantoprazole helps prevent acid reflux and ensures the medication works effectively.
Choice C rationale:
Diarrhea is a possible side effect of pantoprazole, but it is not an expected outcome for all patients. If diarrhea occurs, it should be reported to a healthcare provider.
Choice D rationale:
Antacids can be taken with pantoprazole, but it is generally recommended to take them at different times to avoid potential interactions.
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