The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?
Four -length rails
One-length rail
Two full-length rails
No side rails
The Correct Answer is B
A. Four-length rails.
Explanation: Four-length rails fully enclose the bed and can be considered a more restrictive measure. They may be used when a restraint order is in place, but for an alert patient without such an order, less restrictive alternatives are preferred.
B. One-length rail.
Explanation: Using one-length rails can be a less restrictive alternative when a patient is at high risk for falling. The use of one side rail allows for some protection against falls without fully restraining the patient. This approach helps maintain the patient's mobility and autonomy while still providing a safety measure.
C. Two full-length rails.
Explanation: While using two full-length rails is less restrictive than four-length rails, it is still more restrictive than using only one side rail. The goal is to balance fall prevention with the patient's autonomy.
D. No side rails.
Explanation: Using no side rails may not provide adequate protection for an alert patient at high risk for falling. While avoiding restraints is essential, implementing at least one side rail is a reasonable compromise to enhance safety without fully restricting the patient's movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. HIPAA (Health Insurance Portability and Accountability Act)
Explanation: HIPAA, enacted in 1996, focuses on protecting the privacy and security of individuals' health information. While it is essential in healthcare, it is not directly connected to the nursing home reform mandated by the 1987 law.
B. OASIS (Outcome and Assessment Information Set)
Explanation: OASIS is a set of standardized assessments used in home health care, primarily for Medicare-certified home health agencies. It is not directly connected to the nursing home reform mandated by the 1987 law.
C. Fulmer SPICES
Explanation: Fulmer SPICES is a tool used for assessing common geriatric syndromes, but it is not specifically associated with the nursing home reform mandated by the 1987 law.
D. Resident Assessment Instrument (RAI).
Explanation: The Resident Assessment Instrument (RAI) is associated with nursing home reform mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987. OBRA '87 established regulations and standards for nursing homes, including requirements for comprehensive assessments, care planning, and quality of care. The RAI, specifically the Minimum Data Set (MDS), is a standardized assessment tool used to evaluate the health status and needs of nursing home residents, ensuring a consistent and comprehensive approach to resident assessment and care planning.
Correct Answer is ["A","D","E"]
Explanation
A. Facilitates remote physical assessment and monitoring of chronic conditions
Explanation: Telehealth technology allows healthcare providers to remotely assess and monitor chronic conditions, enabling timely interventions and personalized care plans.
D. Promotes self-management of illness in rural and underserved areas
Explanation: Telehealth technology can help individuals in rural and underserved areas access healthcare services and information, promoting self-management of illnesses and improving overall health outcomes.
E. Decreases costs by reducing hospital readmissions
Explanation: Telehealth technology can contribute to reducing hospital readmissions by enabling remote monitoring, early detection of issues, and timely interventions, ultimately lowering healthcare costs associated with avoidable hospitalizations.
The following options are not accurate in relation to the benefits of telehealth technology:
B. Decreases costs by replacing the role of the nurse with technology
Explanation: Telehealth technology is not meant to replace the role of healthcare professionals, including nurses. Instead, it enhances their ability to provide care by extending access to patients, facilitating communication, and improving monitoring. The goal is to complement healthcare services rather than replace them.
C. Reimbursed by all health care insurances
Explanation: While reimbursement for telehealth services has expanded, it is not universally covered by all healthcare insurances. Coverage varies depending on the payer, state regulations, and the type of telehealth service provided. Reimbursement policies continue to evolve, and not all services may be covered by every insurance plan.
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