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 A

Explanation

A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.

A. "I will instruct visitors to wear a mask when visiting a client who is on contact precautions." B. "I will place a client who has compromised immunity in a negative-pressure airflow room." C. "I will have a client who is on airborne precautions wear a mask when out of her room." D. "I will wear an N95 respirator mask when caring for a client who is on droplet precautions"

Correct Answer is C

Explanation

A. Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.
B.A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client.
C. Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.
D. An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.

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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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