A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Institute rounds every 2 hr. during the day to offer toileting.

Keep four side rails up on the beds at night

Apply vest restraints on the residents who are confused

Accompany residents older than 85 years of age during ambulation

Answer and Explanation

The Correct Answer is A

a.   Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b.   Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c.   Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d.   While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.

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Correct Answer is A

Explanation

a. An asymmetrical thorax could indicate chest trauma which could compromise oxygen delivery.
b. An open fracture of the femur without vessel inury is a lesser priority than chest trauma.
c. Preorbital edema (swelling around the eyes) may indicate facial trauma but is not as immediately lifethreatening as an open fracture.
d. A deep-partial thickness burn on the lower extremities is serious but does not pose an immediate threat to life compared to other injuries such as an open fracture with potential bleeding and risk of infection.

A. Educate the client about the risks of refusing the procedure B. Complete an incident report C. Inform the provider that the client requires clarification about the procedure D. Answer the client’s questions concerning the procedure

Correct Answer is C

Explanation

a. While educating the client about the risks of refusing the procedure is important, it should not be the first action taken when the client does not understand the procedure itself.
b. Completing an incident report is not necessary in this situation, as there is no indication of an adverse event or error.
c. When a client does not understand a procedure, it is essential to inform the provider so that they can provide clarification and address any questions or concerns the client may have.
d. While answering the client's questions is important, the nurse may not have the expertise or authority to provide the level of clarification required. It is best to involve the provider in this situation.

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A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

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