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.
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Related Questions
Correct Answer is B
Explanation
a. A system for tracking client information: While important for managing patients during a disaster, it may not be the highest priority resource in response to a bioterrorism event where protection against exposure to hazardous materials is paramount.
b. A sufficient supply of personal protective equipment: In a bioterrorism event, such as exposure to biological agents, personal protective equipment (PPE) is critical to prevent the spread of pathogens and protect healthcare workers and patients from contamination.
c. A mental health specialist on the response team: Mental health support is important for both staff and patients during and after a disaster, but it may not be the highest priority resource in the immediate response to a bioterrorism event.
d. A network for communication between staff members and families: Communication is essential during any disaster response, but ensuring an adequate supply of personal protective equipment takes precedence in the face of potential exposure to biological agents.
Correct Answer is A
Explanation
a. In emergency situations where obtaining informed consent is not feasible due to the client's unconscious state and immediate need for surgery to preserve life or prevent further harm, the client may be transported to the operating room without obtaining formal consent. This action is based on the principle of implied consent for emergent, life-saving interventions.
b. Delaying surgery to obtain informed consent could result in further harm to the client if immediate intervention is necessary to stabilize their condition.
c. Obtaining telephone consent from the facility administrator is not appropriate in this situation, as the client's immediate medical needs take precedence over administrative procedures.
d. Asking the anesthesiologist to sign the consent is not appropriate, as consent should ideally be obtained from the client or their legally authorized representative.
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