A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the clients to use the call light.

Move overbed tables away from the bed.

Place a fall risk wristband on each of the clients.

Perform client checks every 4 hr.

Keep the clients' rooms dark.

Answer and Explanation

Correct Answer : A,B,C,D

A. Instruct the clients to use the call light.

Encouraging clients to use the call light enables them to request assistance when needed, reducing the risk of falls if they need help to move or get out of bed.

B. Move overbed tables away from the bed.

Clearing the area around the bed, including overbed tables, reduces obstacles and potential hazards that clients might trip over or get tangled in.

C. Place a fall risk wristband on each of the clients.

Identifying clients at risk for falls by using wristbands helps alert all healthcare staff to take necessary precautions and provide appropriate assistance to prevent falls.

D. Perform client checks every 4 hr.

Regular client checks allow the nurse to monitor their condition, reposition them if necessary, assist with toileting needs, and ensure they're safe, especially during the night when falls might be more likely.

E. Keep the clients' rooms dark.

Keeping the room dimly lit during the night can help clients sleep better but should still provide enough light for safe movement. Complete darkness might increase the risk of falls if clients need to move around.

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Correct Answer is A

Explanation

A. "I need to talk to you about unit expectations regarding timely completion of tasks."

This statement is non-confrontational and focuses on discussing the expectations of the unit regarding task completion. It allows the nurse to address the specific behavior (taking long breaks and making personal phone calls) without making accusatory or negative statements.

B. "You have been very inconsiderate of others by not completing your share of the work."

This statement may be perceived as accusatory and could escalate the conflict. It is important to communicate concerns without placing blame.

C. "Several staff members have commented that you don't do your fair share of the work."

This statement involves bringing in third-party opinions, which may not be the most direct and effective way to address the issue. It's better to address the concern directly with the individual involved.

D. "If you don't do your share of the work, I will have to inform the nurse manager."

Threatening to inform the nurse manager without first addressing the issue through communication can escalate the conflict. It's generally more productive to attempt to resolve conflicts through open and direct communication before involving higher authorities.

A. Provide support by holding the client's arm. B. Maintain a narrow base of support. C. Lower the client to the floor. D. Lean the client toward the wall.

Correct Answer is C

Explanation

A. Provide support by holding the client's arm:

While providing support is essential, holding the client's arm may not prevent a fall. It's better to focus on a controlled descent to the floor.

B. Maintain a narrow base of support:

Maintaining a narrow base of support is not advisable when a client is falling. A wider base of support provides more stability.

C. Lower the client to the floor:

This is the correct action. When a client begins to fall, the nurse should lower them to the floor in a controlled manner to minimize the risk of injury.

D. Lean the client toward the wall:

Leaning the client toward the wall may not provide sufficient support during a fall. The goal is to lower the client to the floor in a way that minimizes the risk of injury.

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A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with two assistive personnel (AP). The nurse notes that one of the APs has been taking long breaks and making personal phone calls. Which of the following statements should the nurse make to resolve this conflict?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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