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 D

Explanation

- A: Night sweats and fever could indicate an infection or a chronic condition, which, while important, may not require immediate attention compared to life-threatening conditions.
- B: Compound fractures are serious and require medical attention, but they are not immediately life-threatening if the patient is stable.
- C: Severe vomiting and diarrhea can lead to dehydration and electrolyte imbalance, which are concerning but can be managed with prompt treatment and do not typically pose an immediate threat to life.
- D: Soot markings around the naris indicate possible inhalation injury from a fire, which is a critical condition that can rapidly worsen and lead to airway compromise, making it the highest priority for immediate assessment and intervention.

A. Store opened bottles of normal saline in a refrigerator for up to 48 hours B. Wait to dispose of sharps containers until they are completely full C. Use clean gloves rather than sterile gloves for colostomy care D. Return unused supplies from the bedside to the unit’s supply stock

Correct Answer is C

Explanation

A. Opened bottles of normal saline should be discarded after 24 hours to prevent contamination, even if stored in a refrigerator. Keeping them longer could increase the risk of infection, making this practice unsafe.

B. Sharps containers should be disposed of when they are three-quarters full, not completely full, to prevent needlestick injuries and ensure staff safety. This is a critical safety measure, not an appropriate cost-containment strategy.

C. Using clean gloves rather than sterile gloves for colostomy care is an appropriate cost-saving measure without compromising care. Clean gloves are sufficient for this procedure and help reduce unnecessary use of sterile supplies, which are more expensive.

D. Unused supplies from the bedside should not be returned to the supply stock due to infection control protocols. Once supplies have been taken to the bedside, they are considered contaminated and should be disposed of, not reused.

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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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