A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

Place the bedside table 0.9 m (3 feet) away from the bed.

Provide the client with a night light.

Elevate full-length side rails on both sides of the client's bed.

Keep the client's room temperature at 18° C (64.4° F).

Answer and Explanation

The Correct Answer is B

A. Place the bedside table 0.9 m (3 feet) away from the bed:

While having a bedside table nearby can be convenient for clients to access essential items, the specific distance of 0.9 m (3 feet) is not a standard guideline for falls prevention. Placing the bedside table closer to the bed may actually improve accessibility for the client, but it's not the most crucial action for falls prevention in this scenario.

B. Provide the client with a night light.

Falls prevention strategies aim to create a safe environment for clients at risk of falling. Providing a night light helps improve visibility during nighttime, reducing the risk of falls due to poor lighting. It assists clients in navigating their surroundings safely, especially when getting out of bed during the night.

C. Elevate full-length side rails on both sides of the client's bed:

Using full-length side rails on the bed can increase the risk of entrapment and injury, especially for clients at risk of falls. Current evidence suggests that the use of physical restraints, such as full-length side rails, does not effectively prevent falls and may contribute to adverse outcomes.

D. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for client comfort, the specific temperature of 18°C (64.4°F) is not a standard guideline for falls prevention. Instead, ensuring a comfortable temperature range based on individual client preferences and environmental factors is appropriate.

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Correct Answer is D

Explanation

A. Hypertension in a parent: While a family history of hypertension may increase the risk of developing high blood pressure, it is considered a non-modifiable risk factor because individuals cannot change their genetic predisposition. However, individuals can take steps to manage hypertension through lifestyle modifications and medication.

B. Cultural beliefs: Cultural beliefs may influence health behaviors and attitudes toward health care, but they are not directly modifiable risk factors for heart disease. However, healthcare providers can work with individuals to address cultural barriers and develop culturally sensitive strategies for promoting heart-healthy behaviors.

C. Air quality: Environmental factors such as air pollution can contribute to cardiovascular disease risk, but air quality is not a modifiable risk factor for individuals on an individual level. However, efforts to improve air quality through environmental policies and regulations can help reduce population-level risk of heart disease.

D. Physical inactivity

Modifiable risk factors are those that can be changed or controlled to reduce the risk of developing a particular health condition. Physical inactivity is a modifiable risk factor because individuals can make lifestyle changes to increase their level of physical activity, which can help lower their risk of heart disease. Regular exercise has been shown to improve cardiovascular health by strengthening the heart, reducing blood pressure, improving cholesterol levels, and maintaining a healthy weight.

A. Reposition the client every 4 hr. B. Raise the head of the client's bed to a 60° angle. C. Ensure the client's heels are not touching the mattress. D. Massage the client's bony prominences.

Correct Answer is C

Explanation

A. Reposition the client every 4 hours:

While repositioning is essential for preventing pressure injuries, the recommended frequency for repositioning depends on the individual client's condition, risk factors, and facility protocols. Four-hour intervals may not be sufficient for some clients, especially those at higher risk, and more frequent repositioning may be necessary.

B. Raise the head of the client's bed to a 60° angle:

Raising the head of the bed to a 60° angle may help with positioning for comfort and respiratory support but does not directly address the prevention of pressure injuries. In fact, maintaining the head of the bed elevated at such a high angle for prolonged periods could potentially increase pressure on the sacrum and increase the risk of pressure injuries in other areas.

C. Ensure the client's heels are not touching the mattress.

Keeping the client's heels off the mattress helps to alleviate pressure on this vulnerable area, reducing the risk of pressure injuries. Pressure injuries commonly occur over bony prominences when pressure is exerted on the skin over an extended period, leading to tissue damage. The heels are particularly susceptible due to the limited tissue padding and continuous pressure when lying in bed. Elevating the heels with appropriate support, such as foam pads or pillows, helps to redistribute pressure and minimize the risk of pressure injuries.

D. Massage the client's bony prominences:

Massaging bony prominences is contraindicated for clients at risk of pressure injuries as it can increase friction and shear forces on the skin, leading to tissue damage. Massage should be avoided over areas prone to pressure injuries to prevent further trauma to the skin.

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