The nurse is planning care for a client who is experiencing confusion. Which action by the nurse ensures safety for this client?
A) Keep the windows in the client's room closed.
B) Keep the side rails up on the bed when the client is with a staff member.
C) Place the call bell next to the client.
D) Administer ordered medication.
Answer: C
To prevent falls in the confused client, the nurse should place the call bell next to the client so that the client does not fall trying to reach for it. The bed rails do not need to be up when the client is with a staff member but should be up if the client is alone. Most agency windows are kept closed or are the type that cannot open wide enough to cause injury. Administering ordered medication will not prevent injury to the client.
You might also like to view...
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.)
a. "How frequently do you drink alcohol?" b. "Have you ever had sex with a man?" c. "Do you have a family history of cancer?" d. "Have you ever worked as a plumber?" e. "Were you previously incarcerated?"
A 40-year-old woman is prescribed dantrolene. The nurse should monitor the client for:
a. gastrointestinal upset. c. hepatotoxicity. b. increased risk of urinary tract infection. d. nephrotoxicity.
The client has sustained damage to Wernicke's area in the temporal lobe from a brain attack (stroke). Which of the following should the nurse anticipate when caring for this client?
1. The client will be unable to recall past events. 2. The client will demonstrate difficulty articulating words. 3. The client will have difficulty understanding language. 4. The client will have difficulty moving one side of the body.
Most facilities require that several basic tests be performed on all patients before surgery. A nurse identifies that these tests include all of the following except
1. Electrocardiogram (EKG). 2. Complete blood cell count (CBC). 3. Blood urea nitrogen (BUN). 4. Urinalysis (UA).