A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the clients to use the call light.

Move overbed tables away from the bed.

Place a fall risk wristband on each of the clients.

Perform client checks every 4 hr.

Keep the clients' rooms dark.

Answer and Explanation

Correct Answer : A,B,C,D

A. Instruct the clients to use the call light.

Encouraging clients to use the call light enables them to request assistance when needed, reducing the risk of falls if they need help to move or get out of bed.

B. Move overbed tables away from the bed.

Clearing the area around the bed, including overbed tables, reduces obstacles and potential hazards that clients might trip over or get tangled in.

C. Place a fall risk wristband on each of the clients.

Identifying clients at risk for falls by using wristbands helps alert all healthcare staff to take necessary precautions and provide appropriate assistance to prevent falls.

D. Perform client checks every 4 hr.

Regular client checks allow the nurse to monitor their condition, reposition them if necessary, assist with toileting needs, and ensure they're safe, especially during the night when falls might be more likely.

E. Keep the clients' rooms dark.

Keeping the room dimly lit during the night can help clients sleep better but should still provide enough light for safe movement. Complete darkness might increase the risk of falls if clients need to move around.

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Correct Answer is D

Explanation

A. Move any clients in the immediate vicinity.

This is a reasonable next step, ensuring the safety of clients in close proximity to the potentially hazardous situation.

B. Close the fire doors on the unit.

Closing fire doors is important for containing the spread of smoke and fire, but it may be a secondary action after alerting others to the emergency using the fire alarm.

C. Use a fire extinguisher on the outlet.

While fire extinguishers can be useful in certain situations, using one on an electrical fire can be dangerous. It's generally recommended to leave firefighting to trained personnel and focus on evacuation and alerting others.

D. Activate the fire alarm.

Activating the fire alarm is the priority because it alerts everyone in the facility to the potential danger, ensuring a prompt and coordinated response. It initiates the facility's fire response plan and helps in the evacuation of patients if necessary.

A. "I need to talk to you about unit expectations regarding timely completion of tasks." B. "You have been very inconsiderate of others by not completing your share of the work." C. "Several staff members have commented that you don't do your fair share of the work." D. "If you don't do your share of the work, I will have to inform the nurse manager."

Correct Answer is A

Explanation

A. "I need to talk to you about unit expectations regarding timely completion of tasks."

This statement is non-confrontational and focuses on discussing the expectations of the unit regarding task completion. It allows the nurse to address the specific behavior (taking long breaks and making personal phone calls) without making accusatory or negative statements.

B. "You have been very inconsiderate of others by not completing your share of the work."

This statement may be perceived as accusatory and could escalate the conflict. It is important to communicate concerns without placing blame.

C. "Several staff members have commented that you don't do your fair share of the work."

This statement involves bringing in third-party opinions, which may not be the most direct and effective way to address the issue. It's better to address the concern directly with the individual involved.

D. "If you don't do your share of the work, I will have to inform the nurse manager."

Threatening to inform the nurse manager without first addressing the issue through communication can escalate the conflict. It's generally more productive to attempt to resolve conflicts through open and direct communication before involving higher authorities.

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A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

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