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.
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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Related Questions
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.
Correct Answer is D
Explanation
A. "Unlike an x-ray, the MRI allows you to move around a bit":
This statement is not accurate. During an MRI, it is important for the client to remain as still as possible to obtain clear images. Movement can result in blurred images.
B. "Your exposure to radiation will be minimal":
This statement is not applicable to MRI, as MRI does not use ionizing radiation. It uses a strong magnetic field and radio waves to generate images, making it different from x-rays in terms of radiation exposure.
C. "You will not be able to talk to the technician during the procedure":
While it is essential for the client to remain still during an MRI, communication with the technician is generally possible through an intercom system. The client may be given instructions and reassurance during the procedure.
D. "You'll have to remove metal objects such as watches and body jewelry":
This is the correct statement. Metal objects can interfere with the magnetic field used in MRI and can pose a safety risk. Therefore, clients are required to remove any metal objects before undergoing an MRI.
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