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 C
Explanation
a. Green tags are used for the "walking wounded" who will need medical care at some point after more critical injuries have been treated. This would not be appropriate for a client with full thickness burns on 72% of his body, as this condition is life-threatening and requires immediate attention.
b. Yellow tags are for those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. This client's condition, however, is too critical for a yellow tag.
c. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
d. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
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Correct Answer is B
Explanation
a. A system for tracking client information: While important for managing patients during a disaster, it may not be the highest priority resource in response to a bioterrorism event where protection against exposure to hazardous materials is paramount.
b. A sufficient supply of personal protective equipment: In a bioterrorism event, such as exposure to biological agents, personal protective equipment (PPE) is critical to prevent the spread of pathogens and protect healthcare workers and patients from contamination.
c. A mental health specialist on the response team: Mental health support is important for both staff and patients during and after a disaster, but it may not be the highest priority resource in the immediate response to a bioterrorism event.
d. A network for communication between staff members and families: Communication is essential during any disaster response, but ensuring an adequate supply of personal protective equipment takes precedence in the face of potential exposure to biological agents.
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