A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select All that Apply.)
Assess the client every 4 hours.
Place a fall-risk identification band on the client's wrist.
Keep the client's room dark at night.
Teach the client to use the call light.
Keep the client's bed in the lowest position.
Correct Answer : B,D,E
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
A. Filling out an occurrence form is necessary for documentation and accountability but is not the immediate priority after a medication error.
B. Administering the medication to the correct client should be done, but first, the nurse must ensure the safety and well-being of the client who received the wrong medication.
C. Notifying the client's provider is essential, but the nurse should first assess the client's condition to determine if any immediate actions are necessary.
D. Checking the client's vital signs is the first action the nurse should take to assess the client's current condition and any potential adverse effects from receiving the incorrect medication.
Correct Answer is C
Explanation
A. Performing the final medication check in the area where the medication was obtained does not ensure the correct patient is receiving the medication.
B. Documenting after administration does not allow for a final check of the medication against the patient’s identity and allergies.
C. Performing the final check at the client's bedside before administration allows the nurse to confirm the patient's identity, the medication's appropriateness, and the dosage immediately before giving it.
D. Reviewing the prescription at the nurses' station may not account for patient-specific factors that need to be confirmed at the bedside.