The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

Placing a high risk for falls armband on the patient

Checking on the patient once a shift

Keep the bed in the lowest position

Placing all four side rails in the "up" position

Maintain call light within reach of the patient

Answer and Explanation

Correct Answer : A,C,E

A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Irrigate and perform a dressing change for a client who has a pressure injury wound: This task requires specialized knowledge and skill, particularly in wound care management. It involves assessing the wound, choosing appropriate dressings, and monitoring for signs of infection, which are beyond the scope of duties for assistive personnel.
B. Obtain a daily weight on a client who has heart failure: This task is suitable for delegation to an assistive person because it is a routine, non-invasive procedure that does not require clinical judgment or assessment. It helps in monitoring the client's condition, especially in heart failure management.
C. Teach the use of an incentive spirometer to a postoperative client: Teaching involves educating the client on the proper technique and benefits of using the device, which requires nursing judgment and the ability to address questions or concerns. This task should be performed by a nurse.
D. Administer oral PRN pain medication to a client who has arthritis: Administering medications involves evaluating the client’s pain level, assessing potential side effects, and ensuring the correct medication is given, which requires a nurse’s clinical judgment and knowledge.

A. Clean hands with soap and water after caring for the client B. Place the client in a room with negative pressure airflow C. Wash hands for 10 seconds after caring for the client D. Apply a mask on the client when they are outside their room

Correct Answer is A

Explanation

A. Clean hands with soap and water after caring for the client: C. difficile spores are resistant to alcohol-based hand sanitizers. Therefore, it is essential to use soap and water to effectively remove the spores from hands.
B. Place the client in a room with negative pressure airflow: C. difficile is not an airborne infection, so negative pressure airflow is not required. This measure is typically used for infections such as tuberculosis.
C. Wash hands for 10 seconds after caring for the client: Handwashing with soap and water should be done for at least 20 seconds to effectively remove C. difficile spores.
D. Apply a mask on the client when they are outside their room: A mask is not necessary for clients with C. difficile, as the infection is not transmitted through respiratory droplets but rather through fecal-oral transmission.

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The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

36: A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive person?

Correct Answer is B

Explanation

nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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