A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Keep the four side rails up on beds at night.

Institute rounds every 2 hr during the day to offer toileting

Accompany residents older than 85 years of age during ambulation

Apply vest restraints on residents who are confused.

Answer and Explanation

The Correct Answer is B

A.   Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B.   Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C.   Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D.   Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.

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Correct Answer is C

Explanation

A. While an N95 respirator might be used for airborne precautions, for droplet precautions, a surgical mask is sufficient.
B. While an air filtration system might be beneficial for infection control, it is not a specific requirement for implementing droplet precautions.
C. Wearing a surgical mask within a close proximity (around 3 feet) of the client aligns with the guidelines for droplet precautions.
D. Assigning the client to a room with positive airflow is not necessary for implementing droplet precautions, which focus on preventing transmission through respiratory droplets.

A. Accompanying a client who just had a wound debridement to physical therapy B. Reinforcing dietary teaching with a client who has heart disease C. Obtaining a urine specimen from an older adult client D. Providing postmortem care for a client who has just died

Correct Answer is B

Explanation

A. Accompanying a client to physical therapy is a task that can be appropriately delegated to an AP, as it does not require clinical judgment or advanced nursing knowledge. This task does not require the skills of an LPN.

B. Reinforcing dietary teaching with a client who has heart disease is within the scope of practice for an LPN. LPNs can reinforce teaching that has already been initiated by the registered nurse (RN). This task involves some level of knowledge and skill but does not require independent clinical judgment, making it suitable for the LPN.

C. Obtaining a urine specimen from an older adult client is a task that can be delegated to an AP, as it is a routine procedure that does not require nursing assessment or decision-making. This task does not require the skills of an LPN.

D. Providing postmortem care for a client who has just died is a task that can be appropriately delegated to an AP. This task involves following established protocols and does not require clinical judgment or advanced nursing skills. It is not necessary to assign this task to an LPN.

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A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

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