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 D

Explanation

A. "MSO4 10 mg IVP q4° prn for pain" lacks clarity in abbreviation and dosing instructions.
B. "MS 10 mg IV every 4 pm for pain" contains an unclear frequency and timing.
C. "Morphine sulfate 10 mg IV q4h IV pm for pain" contains redundant dosing information and unclear timing.
D. "Morphine sulfate 10mg every 4 hours IV prn for pain" provides clear and appropriate information regarding medication, dosage, route, frequency, and indication.

A. A client who is at 39 weeks of gestation and has a negative contraction stress test B. A client who is at 35 weeks of gestation and has a biophysical profile of 6 C. A client who is at 37 weeks of gestation and has an US ratio of 2:1 D. A client who is at 28 weeks of gestation and has a negative Coombs' titer

Correct Answer is B

Explanation

A. A client at 39 weeks of gestation with a negative contraction stress test is at term and might not require an interdisciplinary care conference if the test results are normal.
B. A client at 35 weeks of gestation with a biophysical profile of 6 might need further evaluation or interventions, making it appropriate to discuss the case in an
interdisciplinary care conference.
C. A client at 37 weeks of gestation with a specific US ratio might require attention, but the significance of the ratio in this context is unclear without additional information.
D. A client at 28 weeks of gestation with a negative Coombs' titer might not require an interdisciplinary care conference solely based on this information.

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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?

Nursing Test Bank

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