Safety and Mobility Needs Flashcards

An RPN is admitting an 82-year-old client to a long-term care facility. The client has a history of osteoporosis, takes a diuretic for hypertension, and wears bifocal glasses. What is the RPN's priority action related to the client's safety?

Answer: Complete a comprehensive fall risk assessment using a standardized tool.

The nursing process dictates that assessment is the first and most critical step. Given the client's multiple risk factors for falls (advanced age, osteoporosis, diuretic use which can cause orthostatic hypotension, and visual impairment), a comprehensive fall risk assessment is the priority. This assessment will guide the development of a person-centered care plan with specific interventions to mitigate these risks.

An RPN is teaching a client how to safely use a standard walker. Which instruction is most important for the RPN to include?

Answer: "Lift the walker, place it a short distance ahead, then step into it with your affected leg first."

The correct sequence for using a standard (non-wheeled) walker is to first lift and place the walker a comfortable distance forward, ensuring all four legs are stable on the ground. The client should then step forward with their weaker or affected leg, followed by the stronger leg. This method maintains a wide base of support and ensures stability throughout the movement.

Which of the following actions by an RPN demonstrates correct principles of body mechanics when preparing to transfer a client from a bed to a wheelchair?

Answer: Raising the bed to a comfortable working height.

Raising the bed to a comfortable working height (typically at the level of the nurse's waist or hips) is a key principle of body mechanics. This action prevents the nurse from bending or stooping, which reduces strain on the back muscles and minimizes the risk of musculoskeletal injury. Other principles include maintaining a wide base of support, bending at the knees, and pivoting with the feet instead of twisting.

An RPN is caring for an older adult client with dementia who is agitated and repeatedly trying to climb out of bed. The client does not respond to verbal redirection. What is the most appropriate initial intervention before considering restraints?

Answer: Place a floor mat next to the bed and lower the bed to its lowest position.

The principle of least restraint requires using all possible alternatives before applying physical or chemical restraints. Lowering the bed to its lowest position and placing a floor mat beside it is an environmental safety intervention that reduces the risk of injury from a fall without restricting the client's movement. It is a priority action when a client is attempting to get out of bed.

An RPN is positioning a client who is immobile to prevent the development of pressure injuries. To effectively relieve pressure on the sacrum and coccyx, which position is most recommended?

Answer: 30-degree lateral (side-lying) position

The 30-degree lateral position is recommended in clinical practice guidelines for preventing pressure injuries. This position shifts the client's weight onto the gluteal muscles, which effectively offloads pressure from the bony prominences of the sacrum, coccyx, and greater trochanter (hip bone).

An RPN is completing a safety check in a client's room. The client is alert, oriented, and mobile with a walker. Which of the following findings poses the greatest immediate safety risk to this client?

Answer: A small spill of water is on the floor between the bed and the bathroom.

For a client who is mobile, particularly with an assistive device like a walker, a spill on the floor creates a significant and immediate slip hazard. This poses a much greater and more direct risk for a fall and injury than the other environmental factors listed. Promptly cleaning spills is a critical safety measure.