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.
Apply vest restraints on residents who are confused.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: While it is important to identify the staff member responsible for leaving sensitive information accessible, it is not the first action that should be taken. The immediate risk of a confidentiality breach must be addressed before investigating the cause.
Choice B Rationale: Notifying the charge nurse is a necessary step, but it is not the most immediate action required. The priority is to secure the confidentiality of the client's information.
Choice C Rationale: Informing the visitor about the confidentiality of records is crucial, but the first action should be to prevent further viewing of the information.
Choice D Rationale: Closing the computer program is the first and most direct action to secure the client's medical information and prevent any further unauthorized access. This action immediately addresses the privacy breach and protects the client's confidential information.
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.
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