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 A
Explanation
A. Determining the location of the pain is the first step, as it helps the nurse understand the nature and source of the pain, guiding appropriate intervention and medication administration.
B. Repositioning the client may provide comfort but should follow an assessment of the pain to ensure targeted interventions.
C. Administering the medication without understanding the specifics of the pain is inappropriate, as it may not adequately address the client’s needs.
D. Reviewing the effects of the pain medication is important but should occur after assessing the pain to ensure the correct medication is administered based on the client’s specific situation.
Correct Answer is A
Explanation
A. Cleaning and drying the area before applying the patch is essential to ensure proper adhesion and effectiveness of the medication. This statement indicates the client understands proper application procedures.
B. Using lotion on irritated skin before applying a new patch can interfere with the patch's ability to adhere and may affect medication absorption. Therefore, this statement indicates a lack of understanding.
C. Removing the old patch and applying a new one in the same location is generally not recommended because it can lead to skin irritation and decreased absorption. This indicates a misunderstanding of proper patch rotation.
D. While pressing the patch securely is important, it is not as critical as ensuring the skin is clean and dry before application. Thus, this statement alone does not indicate full understanding of the teaching.