The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
Provide a walker.
Place a chair on either side of the bed.
Provide a cane.
Place a fall risk wrist band on the client.
The Correct Answer is D
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.
Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.
Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.
Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.
Correct Answer is D
Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
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