Question

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply.

Answer 1

Answer:

1. Position client in high Fowler's for a paracentesis related to end-stage cirrhosis

2. Position client on left side after liver biopsy

3. Position client on side with head, back, and knees flexed after lumbar puncture

4. Position client Trendelenburg on left side if air embolism is suspected

5. Position client with arm raised above head for chest tube placement

Explanation:

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