A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
Apply an ambulation alarm to the client's leg.
Obtain a prescription to restrain the client PRN.
Instruct the client in the use of the call light.
Raise all side rails on the client's bed.
Check on the client hourly.
Correct Answer : A,C,E
Rationale:
A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.
B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.
C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.
D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.
E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. HICS focuses on organizing and managing internal facility operations rather than mobilizing external multidisciplinary responders.
B. HICS does not directly ensure the availability of specific medical supplies; this is usually managed through other systems or protocols.
C. HICS is primarily concerned with internal facility management, not providing additional responders from outside agencies.
D. HICS helps to define roles, responsibilities, and reporting channels within the facility during a disaster, ensuring effective internal management.
Correct Answer is A
Explanation
Rationale:
A. "The client must provide permission to share the records with you." is the correct procedure as medical records are confidential and require patient consent for release to family members.
B. I will ask the nursing supervisor to obtain the medical records for you is not correct unless the client has given permission.
C. The health care provider will share this information with you does not address the need for patient consent.
D. The ethics committee will need to approve this request for you is not applicable; consent from the client is required.
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