The nurse prepares to leave the room after completing a client assessment. What action(s) should a nurse plan to take to promote safety before leaving a client's room? Select all that apply.
Offer comfort measures to the client
Verify that two bedside rails are raised
Ensure the bed is in the lowest position
Thank the client before leaving the room
Check that the bed is in the locked position
Correct Answer : A,C,E
A. Offer comfort measures to the client: Providing comfort measures, such as adjusting pillows, blankets, or positioning, helps prevent discomfort and reduces the risk of the client attempting unsafe movements, promoting overall safety.
B. Verify that two bedside rails are raised: Raising only two bedside rails is not considered a safe practice for preventing falls. Safety guidelines recommend either following facility policy for rail use or using alternative safety measures rather than arbitrarily raising two rails.
C. Ensure the bed is in the lowest position: Keeping the bed in the lowest position reduces the risk of injury if a client attempts to get out of bed independently, helping prevent falls and enhancing safety.
D. Thank the client before leaving the room: While expressing courtesy is important for rapport and communication, it does not directly contribute to the physical safety of the client.
E. Check that the bed is in the locked position: Locking the bed prevents unintentional movement, especially when the client attempts to get in or out, which is essential for fall prevention and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Discuss with the client their risk factors for developing CAD: Family history is a significant non-modifiable risk factor for coronary artery disease. Educating the client about their personal risk helps raise awareness and supports prevention strategies tailored to their needs.
B. Have the client start exercising for at least 30 minutes a day: While exercise is important for cardiovascular health, recommending a specific regimen without first assessing the client’s overall health, readiness, and risk factors may be unsafe.
C. Encourage the client to attend a support group for CAD: Support groups can be beneficial for individuals already diagnosed with CAD, but the client in this scenario has a family history and may not need immediate support group involvement.
D. Instruct the client to begin following a heart-healthy diet: Diet modification is an effective preventive measure, but it should be introduced as part of a broader discussion on risk factors and individualized planning rather than as an immediate directive.
Correct Answer is B
Explanation
A. Appreciate other cultures: Appreciation of other cultures is important, but without first understanding one’s own biases and values, the nurse may unintentionally impose personal beliefs or misunderstand the client’s perspective. Cultural appreciation alone is insufficient for competent care.
B. Assess one's own cultural values, beliefs, and biases: Self-assessment is the first step in providing culturally competent care. By recognizing personal beliefs, assumptions, and potential biases, the nurse can approach clients with greater awareness, respect, and sensitivity, minimizing the risk of culturally inappropriate care.
C. Examine information about other cultures: Learning about other cultures is valuable for understanding traditions, beliefs, and practices. However, this step is most effective after self-reflection, as knowledge alone does not ensure culturally competent interactions.
D. Learn to speak different languages: Language skills can enhance communication and trust with clients, but they are not the initial step. Effective cultural competence begins with self-awareness, which provides a foundation for meaningful and respectful interactions.
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