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 A
Explanation
The correct answer is A. The nurse should apply pressure to the lacrimal punctum, which is located at the inner corner of each eye, after administering eye drops to prevent systemic absorption of the medication and reduce side effects. The nurse should position the child supine or sitting with their head tilted back slightly before administering eye drops, as this allows for easier instillation and prevents spillage of medication. The nurse does not need to flush the eye with normal saline solution before administering eye drops, unless there is debris or discharge in the eye that needs to be removed. The nurse should wipe from the inner to the outer canthus after administering eye drops, as this prevents contamination of the eye and reduces the risk of infection.
Correct Answer is C
Explanation
The correct answer is C. A small, soft-bristled toothbrush is recommended for cleaning a toddler's teeth as it can remove plaque without damaging the gums. The bristles should be angled at 45 degrees, not 90 degrees, to reach under the gum line. A pea-sized amount of toothpaste, not a 5-inch strip, is sufficient for a toddler's toothbrush. Flossing is not necessary until two adjacent teeth touch each other, which usually happens around age 2 or 3.
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