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.
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Correct Answer is D
Explanation
A. Using technical language can confuse the client and hinder understanding. Educational sessions should use clear and simple language.
B. Starting with the least important information may lead to client confusion or lack of retention of critical details about the medication. Important information should be prioritized.
C. Turning on the television can be distracting for the client, making it difficult for them to focus on the medication education. A quiet environment is more conducive to learning.
D. Providing educational material written at a 6th grade reading level ensures that the information is accessible and understandable for the client, promoting better comprehension and adherence to medication regimens.
Correct Answer is A
Explanation
A. A private, negative-pressure room is essential for clients suspected of having tuberculosis (TB) to prevent airborne transmission. This setup helps contain airborne pathogens and protects other clients and staff.
B. A private, positive-pressure room is inappropriate for this situation because it is designed for immunocompromised patients, not those with potential infectious diseases.
C. A semi-private, negative-pressure room would not provide adequate isolation for a client with suspected TB, increasing the risk of transmission to another patient.
D. A semi-private, positive-pressure room is also inappropriate, as it poses a risk of spreading infectious agents to others in the facility.