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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Telephone consent from the facility administrator might not be sufficient for the specific informed consent required for surgery on an unconscious client.
B. Delaying surgery to ensure proper informed consent is obtained is not appropriate since the client is in a critical condition and delaying surgery might cause death.
C. Asking the anesthesiologist to sign the consent is not appropriate as the responsibility for obtaining informed consent typically lies with the surgeon or responsible provider.
D. Transporting the client to the operating room without informed consent is appropriate in emergency situations where the client is unconscious.

A. A client who has an open fracture of the femur B. A client who has periorbital ecchymosis C. A client who has a deep partial thickness burn on the lower extremities D. A client who has an asymmetrical thorax

Correct Answer is D

Explanation

Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.

Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.

Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.

Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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