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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Provide continuous monitoring of this client: Continuous monitoring is essential to ensure the client's safety while in seclusion, particularly given their agitated and potentially harmful behavior.
Obtain provider prescription for seclusion or restraints: It's necessary to ensure that the use of seclusion is appropriately authorized and documented, following the facility's protocol and legal requirements.
Correct Answer is A
Explanation
Rationale:
A. Comparing the number of medication errors before and after implementing changes provides a direct measure of the effectiveness of those changes.
B. Conducting a study on costs is relevant but not directly related to evaluating the effectiveness in reducing medication errors.
C. Establishing a benchmark is useful for setting standards but does not measure the impact of changes already implemented.
D. Quantifying staff satisfaction is important for assessing the acceptance of changes but does not directly measure the effectiveness in reducing errors.
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