The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?
Apply a vest restraint prophylactically to confused residents.
Accompany residents older than 80 years during ambulation.
Encourage clients to wear rubber-soled shoes.
Leave the hall lights on during the night.
The Correct Answer is C
Choice A: Applying restraints should not be the first approach in fall prevention and is associated with risks and ethical considerations.
Choice B: Accompanying residents during ambulation is a helpful practice but may not be feasible at all times. It's essential to promote independence when possible.
Choice C: Encouraging clients to wear rubber-soled shoes is an important fall prevention measure, as it can provide better traction and stability when walking.
Choice D: Leaving the hall lights on during the night may be helpful, but it is not the most critical intervention for fall prevention. Proper footwear and other measures should take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Performing a physical assessment of the newborn is important but should not be the first action when the infant is handed to the nurse during a cesarean delivery.
Choice B: Determining an APGAR score is important for assessing the newborn's overall condition, but allowing the mother to touch the infant should be the first action.
Choice C: Drying the infant under a warming unit is an important step to maintain the infant's body temperature, but allowing the mother to touch the infant should be prioritized first.
Choice D: Allowing the mother to touch the infant immediately after delivery is a crucial bonding and comforting moment for both the mother and the newborn. It should be the first action taken before other assessments or interventions.
Correct Answer is A
Explanation
Choice A: Performing a fundal massage is the first priority in this situation to assess and manage uterine tone and prevent postpartum hemorrhage.
Choice B: Drawing blood for hemoglobin and hematocrit can be important but is not the immediate priority when the client has just delivered outside the hospital.
Choice C: Obtaining a complete obstetrical history is important but can be done after addressing the immediate postpartum concerns.
Choice D: Inspecting the perineum for lacerations is also important but should be done after addressing uterine tone and hemorrhage prevention.
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