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. A primigravida client who is one day postoperative following a cesarean section and has a PCA pump B. A multigravida client who has preeclampsia and is receiving misoprostol for the induction of labor C. A client who has gestational diabetes and is receiving biweekly nonstress tests D. A client who is at 32 weeks gestation and has premature rupture of membranes

Correct Answer is A

Explanation

a. Postoperative care, especially for a client with a PCA pump (Patient-Controlled Analgesia), requires skills commonly found in medical-surgical units, making it suitable for an RN with experience in that area.
b. Managing preeclampsia and labor induction involves obstetric-specific knowledge and skills, which are better suited for a nurse with experience in obstetrics.
c. Gestational diabetes management and nonstress tests are part of routine obstetrical care and do not necessarily require specialized medical-surgical skills.
d. A client with premature rupture of membranes at 32 weeks gestation requires close monitoring and potentially specialized obstetric care, not typically provided by medical-surgical nurses.

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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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