What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.

Restrain the patient with a chemical sedative.

Encourage the patient to use grab bars located near toilets and showers.

Place the call light within the patient's reach.

Conduct rounds every four hours.

Apply brakes on wheelchairs and bed.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale:

Restrain the patient with a chemical sedative. Rationale: Restraints, especially chemical sedatives, should be avoided whenever possible due to the risk of complications and patient distress. Restraints can lead to decreased mobility, increased agitation, and other adverse effects. They should only be used as a last resort and with appropriate justification, such as ensuring patient or staff safety in emergency situations.

Choice B rationale:

Encourage the patient to use grab bars located near toilets and showers. Rationale: Installing grab bars in bathrooms helps prevent falls by providing support and stability for patients, especially those with mobility issues. Encouraging their use promotes patient independence and safety while performing essential activities of daily living.

Choice C rationale:

Place the call light within the patient's reach. Rationale: Placing the call light within the patient's reach ensures that the patient can easily summon assistance when needed. Prompt response to patient requests can prevent accidents and falls by addressing the patient's needs in a timely manner.

Choice D rationale:

Conduct rounds every four hours. Rationale: Conducting regular rounds allows healthcare providers to assess the patient's condition, address their needs, and identify potential fall risks. However, the specific frequency of rounds may vary based on the patient's condition and the healthcare facility's policies. Some patients may require more frequent monitoring, especially if they are at a higher risk of falling.

Choice E rationale:

Apply brakes on wheelchairs and beds. Rationale: Applying brakes on wheelchairs and beds prevents unintended movement, enhancing patient safety and reducing the risk of falls. It ensures that the patient's mobility aids remain stationary, providing stability when the patient is transferring or repositioning.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale:

Using correction fluid to correct an erroneous written entry is not appropriate as it can obscure the information and raise questions about the accuracy of the documentation. It is better to strike through the error with a single line, write the correct information, and sign and date the correction.

Choice B rationale:

Documenting changes in the patient's status is crucial for ensuring continuity of care and keeping all healthcare providers informed about the patient's condition.

Choice C rationale:

Leaving a blank line for the charge nurse to add additional documentation is not recommended. Each entry should be complete and include all relevant information at the time of documentation.

Choice D rationale:

Planning to finish charting the procedure after returning from a break is not appropriate. Charting should be done in real-time to ensure accuracy and timeliness of the information.

Choice E rationale:

Charting using military (24-hour) time is appropriate as it reduces confusion and ensures a standardized way of documenting time across different healthcare settings.

A. Flexion. B. Abduction. C. Extension. D. Adduction.

Correct Answer is D

Explanation

Choice D rationale:

Adduction is the movement of a body part toward the midline of the body. When the nurse moves the patient's leg toward the midline of the patient's body, it is an adduction movement of the hip joint. This movement involves bringing the leg back to the body's midline, which is the opposite of abduction, where the leg moves away from the midline.

Choice A rationale:

Flexion refers to the bending of a joint, decreasing the angle between two body parts. This is not the correct term for moving the leg toward the midline; it describes a different movement.

Choice B rationale:

Abduction is the movement of a body part away from the midline of the body. It is the opposite movement to adduction. When the leg moves away from the midline, it is in abduction, not adduction.

Choice C rationale:

Extension refers to the straightening of a joint, increasing the angle between two body parts. It is the opposite movement to flexion. This movement does not involve bringing the leg toward the midline.

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What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What actions taken by a newly licensed nurse are appropriate when documenting on paper? Select all that apply.

Correct Answer is ["B","E"]

Explanation

The nurse performs range of motion by moving the patient's leg toward the midline of the patient's body.This movement would be documented as what of the hip?

Correct Answer is D

Explanation

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