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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Cutaneous anthrax is typically treated with antibiotics, so preparing to administer antibiotics to the client is the appropriate action.
b. While respiratory protection may be necessary in certain situations, such as when dealing with airborne pathogens, anthrax exposure typically does not require an N95 respirator mask.
c. Anthrax is caused by a bacterium, not a virus, so administering an antiviral medication would not be effective in treating the infection.
d. Placing a surgical mask on the client during transfer may not be necessary unless there are specific concerns about the spread of respiratory droplets. However, the primary treatment for cutaneous anthrax is antibiotics, not respiratory precautions.
Correct Answer is A
Explanation
a. Transcutaneous electrical nerve stimulation (TENS) is a form of physical therapy often used for pain management. Therefore, the physical therapist would be the appropriate member of the interdisciplinary team to contact for assistance with TENS.
b. Respiratory therapists primarily focus on respiratory care and would not typically be involved in assisting with TENS therapy.
c. Occupational therapists focus on helping clients perform activities of daily living and may not have specific expertise in managing TENS therapy.
d. While pharmacists are knowledgeable about medications, they may not have the expertise required to assist with TENS therapy, which is a form of physical therapy.
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