An 87-year-old woman is admitted to the hospital. The nurse caring for the woman knows that a common nursing diagnosis for this age group of clients is risk for injury. A priority nursing intervention for this client is to
A) perform a fall assessment.
B) keep the side rails up on the client's bed at nighttime.
C) place a walker at the client's bedside.
D) assess the client's dietary intake for calcium adequacy.
A
You might also like to view...
A resident in a nursing home insists that a priest hear his confession. The resident is very anxious, and the nursing home does not have a Roman Catholic chaplain. Which intervention should the nurse implement?
a. An Episcopal priest is coming to visit the home this evening. Arrange an appoint-ment with her for the resident. b. Report the resident's change in behavior in detail so that the attending physician can appropriately prescribe medication. c. Refer the resident to the staff psychologist to address the underlying cause of the pa-tient's anxiety. d. Look in the local telephone book for a Roman Catholic Church, and ask the priest to visit the resident.
M.L. is a 14-year-old client diagnosed with nephritic syndrome following an overdose of recreational drugs. He is started on an ACE-1 inhibitor and a restricted protein diet by the nephrologist
His parents ask the nurse why he is taking a medication used for hypertension. Her best reply is that: 1. The medication is prescribed to prevent hypertension from developing. 2. Without an ACE-I inhibitor, increased dietary protein would be needed. 3. ACE-I inhibitors also reduce protein loss into the urine. 4. ACE-I inhibitors increase urination and prevent edema.
Which compensatory mechanism is spontaneously used by children diagnosed with tetralogy of Fallot to relieve hypoxic spells?
a. Lying on their left side b. Performing the Valsalva maneuver c. Squatting d. Hyperventilating
The PACU nurse is caring for postoperative patient. The patient's oxygen saturation drops from 98% to 88%. What is the nurse's priority action?
a. Call the anesthesia provider b. Call the surgeon c. Call the rapid response team d. Call the respiratory therapist