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

Institute rounds every 2 hr. during the day to offer toileting.

Keep four side rails up on the beds at night

Apply vest restraints on the residents who are confused

Accompany residents older than 85 years of age during ambulation

Answer and Explanation

The Correct Answer is A

a.   Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b.   Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c.   Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d.   While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.

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Correct Answer is C

Explanation

A. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.

A. An evidence-based nursing journal B. The client's health care provider C. The facility's case manager D. A collaborative, user-edited website

Correct Answer is A

Explanation

a. An evidence-based nursing journal would provide reliable, peer-reviewed information on the prevalence of Tay-Sachs disease, ensuring accuracy and reliability.
b. While the client's health care provider may have general knowledge about Tay-Sachs disease, they may not have specific prevalence statistics readily available.
c. The facility's case manager may assist with coordination of care but may not have specific information about the prevalence of Tay-Sachs disease.
d. Collaborative, user-edited websites may not always provide accurate or reliable information, so they should be used with caution for obtaining medical information.

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A nurse at a long-term 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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