Question 37 - Safety and Infection Control Practice Test for the NCLEX-PN Exam

Use the case study information provided to answer this question.

Which nursing interventions would be the most important to implement for this client?

Select all that apply.

A. Keep the room free from clutter.
B. Place all four bed rails up.
C. Ensure the bed is in the lowest position.
D. Pad the bed rails with blankets.
E. Organize cords and tubing to ensure nothing is stretching across the floor.
F. Only allow plasticware in the client’s room.

Intro to Case

The LPN is taking care of a 43-year-old male client on the medical-surgical floor. He was recently admitted with alcohol withdrawal symptoms.

Nurse’s Notes

2200: Admission assessment completed by RN. Client states he has not had an alcoholic beverage in 10 hours and “doesn’t feel right.” He states he is trying to quit, but doesn’t know if he will be able to without medical treatment. He has been a heavy drinker since he was 14 years old. Client’s hands are visibly shaking and forehead is sweating.

History and Physical

Body System Findings
Neurological Client is AAO x 4. Perrla. Hands shaking and client complaining
of a headache 6/10. Client
has a hx of seizures, anxiety, and depression.
Cardiovascular Hx of hypertension, hyperlipidemia, tachycardia
Respiratory Current 1 PPD smoker. Hx of COPD and OSA. On 2 L of oxygen at night. Client had COVID-19 one month ago.
Musculoskeletal Hx of multiple sclerosis (MS), diagnosed 5 years ago. Client states
he has some weakness at times and
occasional numbness and tingling in
extremities
   

Vital Signs

  2200
BP \(162/86\)
T \(98.7^\circ \text{F}\)
HR \(114\)
RR \(18\)
SpO\(_2\) \(95\%\)

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