A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
Keep the four side rails up on beds at night.
Institute rounds every 2 hr during the day to offer toileting
Accompany residents older than 85 years of age during ambulation
Apply vest restraints on residents who are confused.
Apply vest restraints on residents who are confused.
The Correct Answer is B
A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client at 39 weeks of gestation with a negative contraction stress test is at term and might not require an interdisciplinary care conference if the test results are normal.
B. A client at 35 weeks of gestation with a biophysical profile of 6 might need further evaluation or interventions, making it appropriate to discuss the case in an
interdisciplinary care conference.
C. A client at 37 weeks of gestation with a specific US ratio might require attention, but the significance of the ratio in this context is unclear without additional information.
D. A client at 28 weeks of gestation with a negative Coombs' titer might not require an interdisciplinary care conference solely based on this information.
Correct Answer is B
Explanation
A. Waiting to dispose of sharps containers until they are completely full might compromise safety and infection control practices.
B. Using clean gloves rather than sterile gloves for colostomy care is a possible interventin that can be applied.
C. Returning unused supplies to the unit's supply stock is not correct.
D. Storing opened bottles of normal saline for up to 48 hours might not be compliant with storage guidelines and could risk contamination, potentially increasing costs through wastage or patient harm.
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