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. While educating the client about the risks of refusing the procedure is important, it should not be the first action taken when the client does not understand the procedure itself.
b. Completing an incident report is not necessary in this situation, as there is no indication of an adverse event or error.
c. When a client does not understand a procedure, it is essential to inform the provider so that they can provide clarification and address any questions or concerns the client may have.
d. While answering the client's questions is important, the nurse may not have the expertise or authority to provide the level of clarification required. It is best to involve the provider in this situation.

A. Involve the client’s partner to assist with the teaching session B. Incorporate gestures and hand signals when presenting information C. Validate understanding by interpreting the client’s body language D. Provide an interpreter when obtaining consent for the client

Correct Answer is D

Explanation

a. Involving the client's partner may be helpful for additional support, but it does not ensure accurate communication if the partner also does not speak the same language as the client.
b. While incorporating gestures and hand signals can be useful, they may not fully convey complex medical information and may lead to misunderstandings.
c. Interpreting the client's body language can provide some insight into their understanding, but it may not accurately represent their comprehension of the information.
d. Providing an interpreter ensures accurate communication and understanding between the nurse and the client, promoting effective teaching and informed decision-making.

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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?

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