The nurse is caring for a client with a recent history of falls. Which intervention is most important for the nurse to implement?
Removing tripping hazards from the client's environment.
Providing the client with nonskid footwear.
Educating the client on the correct use of handrails.
Assisting the client with toileting and ambulation.
The Correct Answer is A
Answer: a. Removing tripping hazards from the client's environment. Explanation: Removing tripping hazards from the client's environment is the most important intervention for preventing falls. It helps create a safe and hazard-free environment, reducing the risk of accidental falls.
Incorrect choices: b. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls but may not address all potential fall risks. c. Educating the client on the correct use of handrails is essential, but it may not be the most critical intervention compared to removing environmental hazards. d. Assisting the client with toileting and ambulation is important, but it focuses on direct assistance rather than eliminating hazards from the environment.
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Related Questions
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.
Correct Answer is C
Explanation
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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