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 ["B","E"]
Explanation
A. The provider's name is not an acceptable identifier for verifying the client; it does not confirm the identity of the patient receiving the medication.
B. A facility-assigned identification number is an acceptable identifier as it uniquely identifies the client within the healthcare system.
C. The facility room number is not reliable for identifying clients, as multiple clients can be in the same room or there could be room changes.
D. The partner's full name is not an appropriate identifier for the client; it does not confirm the identity of the patient.
E. The client's full name is an acceptable identifier as it is a primary method to verify the identity of the client before medication administration.
Correct Answer is D
Explanation
A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.
B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.
C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.
D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.