As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

Offer to request a prescription for an indwelling urinary catheter.

Keep a night light on in the client's room.

Put the side rails up and tell the client to call for assistance to the bathroom.

Limit the client's fluid intake in the evening.

Answer and Explanation

The Correct Answer is B

A. Offer to request a prescription for an indwelling urinary catheter.

Indwelling urinary catheters come with their own set of risks and complications. It is generally not recommended to use them solely for the purpose of preventing falls unless there are other medical indications for their use. Catheters increase the risk of infection and other complications, and their use should be based on clear medical necessity.

B. Keep a night light on in the client's room.

This option directly addresses the client's concern about falling during the night. Providing a night light in the room helps to alleviate disorientation, making it safer for the client to navigate to the bathroom. It is a practical and non-invasive intervention.

C. Put the side rails up and tell the client to call for assistance to the bathroom.

While using side rails can be a fall prevention measure, it's important to consider that they are not without risks. Side rails can lead to entrapment or injury if not used appropriately. In addition, telling the client to call for assistance is good advice, but relying solely on this instruction may not address the immediate concern of disorientation in new surroundings.

D. Limit the client's fluid intake in the evening.

While limiting fluid intake in the evening might reduce the frequency of bathroom trips, it is not the most appropriate response to the client's concern. Dehydration can lead to other health issues and should not be used as the primary strategy for fall prevention.

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Correct Answer is D

Explanation

A. Inject the medication deep into the thigh muscle.

This statement is incorrect for subcutaneous heparin administration. Heparin is typically administered subcutaneously in the fatty tissue just under the skin, not into the muscle. Intramuscular injection is not appropriate for heparin.

B. Easy bruising indicates the medication is effective.

This statement is inaccurate. Easy bruising is not an indicator of the effectiveness of heparin. In fact, excessive bruising can be a side effect of anticoagulant therapy, indicating a potential issue with bleeding or clotting.

C. Expect stools to become black and tarry.

This statement is more relevant to medications like iron supplements or upper gastrointestinal bleeding. It is not a common side effect of subcutaneous heparin.

D. Use a soft bristle toothbrush.

This statement is correct. It is important for individuals on anticoagulant therapy, such as heparin, to use a soft bristle toothbrush to minimize the risk of bleeding and gum irritation. Hard bristle toothbrushes can cause gum bleeding, especially in individuals with a tendency for bleeding due to anticoagulant use.

A. Interpreting a client's vital signs B. Providing postmortem care on a client who has died C. Performing a central line dressing change for a client D. Educating a client on the use of a blood glucose monitor

Correct Answer is B

Explanation

A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.

C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.

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As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is to start subcutaneous heparin. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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