The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)
Placing a high risk for falls armband on the patient
Checking on the patient once a shift
Keep the bed in the lowest position
Placing all four side rails in the "up" position
Maintain call light within reach of the patient
Correct Answer : A,C,E
A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer medication for high blood pressure: This is a dependent intervention as it requires a healthcare provider's order and is part of prescribed treatment.
B. Reposition the client every 2 hours: This is an independent nursing intervention, as it involves routine care that nurses can perform without needing a specific provider's order.
C. Starting IV antibiotics: This is a dependent intervention that requires a healthcare provider’s order and typically involves more specialized procedures.
D. Administering medication for pain: This is also a dependent intervention because it requires a healthcare provider's prescription and direction for administration.
Correct Answer is A
Explanation
A. Orthostatic hypotension increases a client's risk of a fall: Correct. Orthostatic hypotension can lead to dizziness or lightheadedness when standing, increasing the risk of falls.
B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: This is not specific enough. Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more when standing.
C. Orthostatic hypotension increases a client's risk of a pulmonary emboli: This is not directly related. Orthostatic hypotension mainly affects balance and fall risk, not the risk of pulmonary emboli.
D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: This is incorrect. Orthostatic hypotension is more commonly assessed by a significant drop in systolic blood pressure rather than diastolic pressure.
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