he nurse is caring for a client who experienced a fall. Which action by the nurse is most appropriate

Documenting the fall incident in the client's medical record

Conducting a comprehensive fall risk assessment.

Implementing fall prevention interventions for the client.

Reporting the fall to the unit manager

Answer and Explanation

The Correct Answer is C

Answer: c. Implementing fall prevention interventions for the client. Explanation: After a fall, the most appropriate action for the nurse is to implement fall prevention interventions for the client. This includes reassessing the client's risk factors, modifying the environment, and providing necessary support and assistance to prevent future falls.

Incorrect choices: a. Documenting the fall incident in the client's medical record is an essential step but should follow the immediate implementation of fall prevention interventions. b. Conducting a comprehensive fall risk assessment is important, but it should be done as part of the ongoing care and assessment rather than immediately after a fall. d. Reporting the fall to the unit manager is necessary for organizational reporting purposes, but it does not directly address the client's immediate safety needs.

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Correct Answer is C

Explanation

Answer: c. Implementing hourly rounding to assess the client's needs. Explanation: Implementing hourlyrounding to assess the client's needs is the most important intervention for preventing falls in a medical-surgical unit. Regular rounding allows the nurse to monitor the client's condition, address any immediate needs, and provide assistance with mobility or other activities, reducing the risk of falls.

Incorrect choices: a. Providing a bedside commode for toileting needs is important for promoting safe toileting, but it does not address the overall risk of falls. b. Placing the client in a private room near the nurses' station may enhance surveillance, but it does not actively prevent falls. d. Educating the client on proper use of assistive devices is essential, but it is not the most critical intervention for fall prevention in the medical-surgical unit setting.

A. Keeping the client's bed in the lowest position. B. Using bed rails to restrict the client's movement. C. Providing the client with nonskid footwear. D. Administering sedative medications at bedtime.

Correct Answer is A

Explanation

Answer: a. Keeping the client's bed in the lowest position. Explanation: Keeping the client's bed in the lowest position is the most appropriate action to prevent falls. A low bed height reduces the risk of injury if the client accidentally falls out of bed.

Incorrect choices: b. Using bed rails to restrict the client's movement is not recommended as it can increase the risk of entrapment or injury. Bed rails should be used judiciously and with caution. c. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls, but it is not the most crucial intervention in this scenario. d. Administering sedative medications at bedtime increases the risk of falls by affecting the client's balance and alertness. Sedatives should be used sparingly and only when necessary.

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he nurse is caring for a client who experienced a fall. Which action by the nurse is most appropriate

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client on a medical-surgical unit. Which intervention is most important for preventing falls in this client population?

Correct Answer is C

Explanation

The nurse is caring for a client who is at risk for falls. Which action by the nurse is most appropriate to prevent falls?

Correct Answer is A

Explanation

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