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A nurse is reviewing the plan of care for a client who is currently admitted to a medical surgical unit.
Which intervention should the nurse include to promote patient safety and prevent falls?

A.

Keep the bed in the lowest position at all times.

B.

Ensure the room is dimly lit during the daytime hours.

C.

Encourage the client to walk barefoot for better grip.

D.

Place all four side rails in the upright position.

Answer and Explanation

The Correct Answer is A

Patient safety protocols require the application of fall prevention strategies and environmental management. Knowledge of hospital safety standards, mobility mechanics, and the legal implications of restraints is necessary to select interventions that minimize injury risks while maintaining a safe therapeutic environment.

Choice A rationale

Keeping the bed in the lowest position minimizes the vertical distance to the floor, significantly reducing the impact force and potential for injury if a client attempts to exit the bed unassisted. This is a primary fall prevention standard.

Choice B rationale

Dim lighting during daytime hours decreases visual acuity and increases the risk of environmental trips or missteps. Adequate illumination is required for clients to identify obstacles, perceive depth accurately, and navigate their surroundings safely during active hours.

Choice C rationale

Barefoot walking increases the risk of slipping on smooth hospital floor surfaces. Safety protocols mandate non-skid footwear or socks with rubber grips to provide necessary traction and stability, preventing falls related to a lack of foot-to-floor friction.

Choice D rationale

Raising all four side rails is classified as a physical restraint in many jurisdictions and can actually increase injury severity. Clients may attempt to climb over the rails, leading to falls from a much greater height.

 


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

In the management of a sub-massive Pulmonary Embolism (PE), all of these actions are indicated because the client will be started on a rigorous anticoagulation regimen (typically a transition from Heparin to Warfarin/DTI).

  • aPTT & Protamine Sulfate: Indicated for monitoring and reversing Heparin therapy, which is usually the initial treatment for an acute PE.
  • INR & Phytonadione: Indicated for monitoring and reversing Warfarin (Coumadin) therapy, which is often started simultaneously with Heparin for long-term management.
  • Hematocrit: Essential to monitor for internal bleeding or occult blood loss while on anticoagulants.
  • Platelet levels: Necessary to screen for Heparin-Induced Thrombocytopenia (HIT), a serious complication of heparin therapy.
  • Bleeding/Bruising Assessment: This is the most critical nursing assessment for any client receiving anticoagulation to ensure safety and catch hemorrhage early.

Correct Answer is D

Explanation

This question involves delegation principles in hospice care. Knowledge of the scope of practice for volunteers versus clinical staff is required. It focuses on identifying non-clinical, psychosocial support tasks appropriate for an unlicensed, non-medical volunteer to perform.

Choice A rationale

Providing spiritual support is a specialized role typically reserved for chaplains or trained clergy members. While volunteers are supportive, this task involves professional spiritual counseling and assessment beyond a general volunteer scope of practice.

Choice B rationale

Assessing the availability and functionality of medical equipment is a clinical responsibility. The nurse or a medical technician must ensure that the home environment is safe and that technical care requirements are met appropriately.

Choice C rationale

Personal care, such as sponge baths and skin assessments for bony prominences, involves physical contact and monitoring for skin breakdown. These tasks are typically delegated to nursing assistants or home health aides, not volunteers.

Choice D rationale

Volunteers in hospice are trained to provide companionship and emotional presence. Sitting with a client to reminisce provides psychosocial support and comfort, which falls within the volunteer's role of enhancing the client's quality of life.

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