A nurse is caring for an elderly client at risk of injury due to ...

[sheilaspns]

A nurse is caring for an elderly client at risk of injury due to confusion. The client has a stable gait. Which of the following measures should the nurse first take?
 
  A) Waist restraint
  B) Locking lap tray chair
  C) Alarm-activating bracelet
  D) Vest restraint

Question 2

A nurse responds to the call bell and finds another nurse evacuating the client from the room because a garbage can has caught fire. Which of the following actions should the nurse take first?
 
  A) Evacuate the unit.
  B) Pull the fire alarm lever.
  C) Confine the fire.
  D) Extinguish the fire.

[welcom1000]

Answer to Question 1

C
Feedback:
The nurse should use an alarm-activating bracelet for the client because the client has a stable gait. This prevents unnecessary confinement to bed, and the client can move freely without getting off the premises. Waist restraints, vest restraints, and chair restraints are restrictive, and their use should be minimal.

Answer to Question 2

B
Feedback:
The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

[sheilaspns]

Excellent

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