The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

Make sure the bed is low, locked, and call light in reach of patient

Ask the client if they have ordered their dinner

Educate the client on the surgical procedure they are scheduled for in the morning

Check that the client is wearing non-skid socks while in bed

Answer and Explanation

The Correct Answer is A

A. Make sure the bed is low, locked, and the call light is in reach of the patient:

This action is crucial for preventing falls. A low bed reduces the risk of injury if the client were to accidentally fall. Locking the bed prevents unintended movement, and ensuring the call light is within reach allows the client to call for assistance if needed.

B. Ask the client if they have ordered their dinner:

While nutrition is important, it is not the immediate priority after assisting the client back to bed. Safety measures should be addressed first.

C. Educate the client on the surgical procedure they are scheduled for in the morning:

While pre-operative education is important, it is not the immediate concern after assisting the client back to bed. Safety measures for the current situation take precedence.

D. Check that the client is wearing non-skid socks while in bed:

While wearing non-skid socks is a safety measure, ensuring the bed is low, locked, and the call light is accessible is a more immediate and critical action after assisting the client back to bed.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Evaluation:

Both RNs and LPNs engage in the evaluation step of the nursing process. It involves assessing the effectiveness of the care plan and determining whether the desired outcomes have been achieved.

B. Analysis:

The analysis step involves a deeper level of critical thinking and problem-solving. It often includes a more comprehensive examination and interpretation of assessment data to develop the nursing diagnosis, a step that typically falls within the scope of practice for RNs.

C. Implementation:

Both RNs and LPNs are involved in implementing the care plan, which includes carrying out nursing interventions according to the established plan of care.

D. Planning:

Both RNs and LPNs participate in the planning phase, which involves setting goals, establishing priorities, and creating a care plan tailored to the patient's needs.

A. Every four hours. B. Every hour. C. Every shift. D. Every two hours

Correct Answer is D

Explanation

A. Every four hours:

Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.

B. Every hour:

Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.

C. Every shift:

Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.

D. Every two hours:

Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.

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The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing process guides nurses in delivery of care and includes sequential steps. Which step does the registered nurse (RN) perform within the nursing process that is not part of the standard of practice for the licensed practical nurse (LPN)?

Correct Answer is B

Explanation

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

Correct Answer is D

Explanation

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