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An elderly client is hospitalized for the first time.

Which of the following actions ensures the safety of the client? (Select all that apply).

Keep call bell within the client’s reach.

Keep a dim light on at night.

Keep unnecessary furniture out of the way.

Keep all side rails up at all times.

Keep all lights off at night.

Answer and Explanation

Correct Answer : A,B,C

These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.

Keeping a call bell within the client’s reach allows them to ask for help when needed.

Keeping a dim light on at night helps them orient themselves and see their surroundings.

Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.

Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.

Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.

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Correct Answer is D

Explanation

McBurney’s point is located one-third of the distance from the right anterior superior iliac spine to the umbilicus. This is where the base of the appendix is attached to the cecum, which is part of the large intestine. When the appendix becomes inflamed or infected, it causes pain in this area.

Choice A is wrong because the left lower quadrant is where the sigmoid colon and part of the small intestine are located.

These organs are not related to appendicitis.

Choice B is wrong because the left upper quadrant is where the stomach, spleen, and part of the pancreas are located.

These organs are also not related to appendicitis.

Choice C is wrong because the right upper quadrant is where the liver, gallbladder, and part of the small intestine are located. These organs can cause pain in this area if they have problems, but not appendicitis

A. The lack of healing of the stump. B. Ineffective control of the client’s pain. C. The removal of the wrong arm. D. The client being mildly sedated.

Correct Answer is C

Explanation

This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.

Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.

Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.

Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.

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An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

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Naxlex Comprehensive Predictor Exams

In individuals who have appendicitis, the pain will typically localize to McBurney’s point. Which quadrant of the abdomen is McBurney’s point found?

Correct Answer is D

Explanation

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Correct Answer is C

Explanation

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An elderly client is hospitalized for the first time.

Which of the following actions ensures the safety of the client? (Select all that apply).