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.

Answer and Explanation

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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Correct Answer is A

Explanation

Answer: a. "I will use a nightlight in my bedroom and bathroom." Explanation: The statement "I will use a nightlight in my bedroom and bathroom" indicates understanding of the need for adequate lighting to prevent falls during nighttime activities.

Incorrect choices: b. "I will make sure to rush to answer thephone." This statement demonstrates a misunderstanding of the importance of prioritizing safety over rushing to answer the phone, which may increase the risk of falls. c. "I will keep my medication bottles on the kitchen counter." This statement suggests a potential hazard of leaving medication bottles on the counter, which can increase the risk of falls due to clutter and potential spills. d. "I will wear socks with a smooth sole for better comfort." This statement indicates a lack of understanding of the importance of wearing nonskid footwear to maintain traction and prevent slips and falls. Smooth-soled socks may increase the risk of slipping on smooth surfaces.

A. Documenting the fall incident in the client's medical record B. Conducting a comprehensive fall risk assessment. C. Implementing fall prevention interventions for the client. D. Reporting the fall to the unit manager

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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