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 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 ["7"]

Explanation

To give the correct dose of amoxicillin 350 mg PO, the nurse needs to calculate how many ml. of the available solution are equivalent to that amount. The available solution has a concentration of 250 mg/5 mL, which means that every 5 ml. contain 250 mg of amoxicillin. To find out how many ml. are needed for 350 mg, the nurse can use a proportion:

250 mg/5 mL = 350 mg/x mL

Cross-multiplying and solving for x, we get:

x = (350 mg x 5 mL) / 250 mg

x = 7 ml.

Therefore, the nurse should administer 7 ml. of the amoxicillin solution.

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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 assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many ml. should the nurse administer? (Round to the nearest whole number.)

Correct Answer is ["7"]

Explanation

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