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 B
Explanation
The correct answer is B. Productive cough with thick mucus. Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.
Correct Answer is A
Explanation
The correct answer is A. Consume soft, bland foods. The client with stomatitis should avoid spicy, acidic, or rough foods that can irritate the inflamed mucous membranes of the mouth.
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