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 B
Explanation
a. While unfortunate, a minor burn from spilling coffee does not present an ethical dilemma.
b. This situation involves a conflict between parental authority and the adolescent's autonomy, representing an ethical dilemma.
c. This situation may involve ethical considerations, such as whether to report the error, but it does not inherently involve conflicting moral principles.
d. Operating on the wrong side of the body represents a medical error rather than an ethical dilemma.
Correct Answer is B
Explanation
a. Advising the newly licensed nurse to complete less time-consuming tasks first may not address the underlying issue of difficulty focusing and prioritizing care effectively.
b. Recommending that the newly licensed nurse take time to plan at the beginning of his shift can help him organize tasks and prioritize care more effectively.
c. While offering to provide care for his clients while he takes a break is supportive, it does not address the underlying issue of difficulty focusing and prioritizing care.
d. Asking other staff members to take over some of his tasks may be necessary in some situations but should not be the first intervention. Helping the nurse develop strategies to improve focus and organization is more appropriate.
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