Rationale for Choice A:

Arranging for a bedside commode can be helpful for patients who have difficulty ambulating to the bathroom. However, it is not the most effective intervention for preventing falls in an ambulatory and independent patient. In fact, it could potentially increase the risk of falls if the patient attempts to use the commode without assistance or if they become disoriented in the dark.

Research has shown that bedside commodes are associated with an increased risk of falls in hospitalized patients. This is because patients may try to get out of bed to use the commode without assistance, or they may become disoriented in the dark and fall.

Additionally, bedside commodes can be a tripping hazard, especially for patients with impaired mobility.

Rationale for Choice B:

Ensuring the bathroom light is kept on during the night can help to reduce the risk of falls by making it easier for the patient to see. However, it is not the most effective intervention for preventing falls.

Patients may still fall even if the bathroom light is on, especially if they are weak, unsteady, or have impaired vision. Additionally, keeping the bathroom light on all night can disrupt the patient's sleep, which can also increase the risk of falls.

Rationale for Choice C:

Using side rails to keep the patient in bed is not an effective intervention for preventing falls. In fact, it can actually increase the risk of falls by making it more difficult for the patient to get out of bed safely.

Patients may try to climb over the side rails, which can lead to falls.

Additionally, side rails can restrict the patient's movement and make them feel trapped, which can lead to agitation and an increased risk of falls.

Rationale for Choice D:

Implementing a toileting schedule is the most effective intervention for preventing falls in an ambulatory and independent patient. This is because it helps to reduce the patient's need to get out of bed at night to use the bathroom.

When a patient has a scheduled time to toilet, they are less likely to try to get out of bed on their own and risk a fall. Additionally, a toileting schedule can help to prevent incontinence, which can also lead to falls.

Rationale for Choice A:
Documenting and continuing to monitor is a crucial aspect of nursing care; however, in this scenario, it would not be the first action to take. The significant drop in blood pressure warrants immediate intervention to prevent potential complications.
While monitoring is essential, it does not actively address the underlying cause of the hypotension. Relying solely on monitoring could delay necessary interventions and potentially compromise patient safety.
It's important to balance monitoring with timely interventions to ensure optimal patient outcomes. In this case, calling for assistance takes priority over documentation and continued monitoring.
Rationale for Choice B:
Repeating the blood pressure in 15 minutes could delay critical interventions if the hypotension is severe. Timely action is crucial to maintain adequate tissue perfusion and prevent organ damage.
Waiting to recheck the blood pressure could potentially worsen the patient's condition and lead to adverse outcomes. It's essential to act promptly when a significant change in vital signs occurs.
Rationale for Choice D:
While notifying the primary healthcare provider is an important step, it may not be the most immediate action in this situation. The Rapid Response Team is specifically trained to handle acute patient deterioration and can provide timely interventions.
The Rapid Response Team can initiate life-saving measures, such as administering fluids or medications, while the primary healthcare provider is being notified. This ensures that the patient receives prompt and appropriate care.
Rationale for Choice C:
Calling the Rapid Response Team is the most appropriate first action in this scenario because it ensures a rapid and coordinated response to the patient's hypotension.
The Rapid Response Team can quickly assess the patient, initiate interventions, and potentially prevent further complications. They can also facilitate communication and collaboration among healthcare providers.
Early activation of the Rapid Response Team has been shown to improve patient outcomes in various clinical settings, including postoperative care.