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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. In emergency situations where immediate treatment is necessary to stabilize the client and prevent further deterioration, obtaining written consent may not be feasible or necessary. The principle of implied consent applies in emergency situations where the client is unable to provide consent due to their condition.
b. Notifying risk management before initiating treatment is not necessary in this emergency situation, as the priority is to provide timely and appropriate care to the client.
c. Having the client sign a consent for treatment may not be possible if the client is disoriented or incapacitated due to their condition.
d. Contacting the client's next of kin to obtain consent may delay necessary treatment, which could be detrimental to the client's health in an emergency situation.
Correct Answer is A
Explanation
a. An asymmetrical thorax could indicate chest trauma which could compromise oxygen delivery.
b. An open fracture of the femur without vessel inury is a lesser priority than chest trauma.
c. Preorbital edema (swelling around the eyes) may indicate facial trauma but is not as immediately lifethreatening as an open fracture.
d. A deep-partial thickness burn on the lower extremities is serious but does not pose an immediate threat to life compared to other injuries such as an open fracture with potential bleeding and risk of infection.
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