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

Keeping the client's bed in the lowest position.

Using bed rails to restrict the client's movement.

Providing the client with nonskid footwear.

Administering sedative medications at bedtime.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is D

Explanation

the client with a bed alarm system. d. Recommending the use of a cane or walker.

Answer: d. Recommending the use of a cane or walker. Explanation: Recommending the use of a cane or walker is the most appropriate intervention for an older adult client at risk for falls. Assistive devices can provide additional support and stability, helping to maintain balance and reduce the risk of falls.

Incorrect choices: a. Implementing a toileting schedule for the client is important but may not directly address the client's specific fall risk. b. Assessing the client's orthostatic blood pressure is essential for assessing orthostatic hypotension but may not be the most appropriate intervention for addressing fall risk in this scenario. c. Providing the client with a bed alarm system can help alert the nursing staff when the client is attempting to leave the bed, but it does not directly address the client's balance and stability needs.

A. Placing a sign on the client's room door indicating fall risk. B. Encouraging the client to use the call bell for assistance. C. Providing a nonskid mat on the floor beside the client's bed. D. Ensuring the client has adequate lighting in the room.

Correct Answer is B

Explanation

d. Ensuring the client has adequate lighting in the room.

Answer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.

Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an older adult client who is at risk for falls. Which intervention is most appropriate to address the client's specific fall risk

Correct Answer is D

Explanation

A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?

Correct Answer is B

Explanation

The nurse is caring for a client with a recent history of falls. Which intervention is most important for the nurse to implement?

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