A nurse is contributing to the development of a fall-prevention policy for clients with dementia. Which source of information should the nurse identify as the primary guideline for the creation of the policy?

Peer-reviewed nursing journals.

Clinical expertise of facility nurses.

Review of medical records.

Facility performance Indicators.

Answer and Explanation

The Correct Answer is A

Evidence-based policy development relies on the hierarchy of clinical evidence synthesis, prioritizing high-quality research such as systematic reviews and peer-reviewed studies. Fall prevention in dementia requires integration of validated risk factor analysis, geriatric safety research, and standardized clinical guidelines to ensure interventions are both effective and generalizable across populations.

Rationale:

A. Peer-reviewed nursing journals provide the strongest foundation of evidence-based practice, including randomized controlled trials and systematic reviews on fall prevention strategies in dementia. These sources ensure scientific validity, reproducibility, and alignment with current best practice guidelines.

B. Clinical expertise contributes to practical application, but it is subjective and varies between practitioners. While valuable in implementation, it is not the primary source for policy creation compared to systematically validated research evidence.

C. Medical record review provides retrospective data analysis specific to a facility but lacks generalizability. It identifies trends but does not establish evidence-based standards for policy development across broader populations.

D. Facility performance indicators reflect quality metrics and outcomes monitoring, but they are outcome measures rather than evidence sources. They are useful for evaluation, not for establishing foundational clinical policy guidelines.

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Free Nursing Study Resources

Correct Answer is ["33"]

Explanation

Step 1: Identify formula
gtt/min = (Total volume × Drop factor) ÷ Time (in minutes)

Step 2: Convert time
30 minutes = 30 min

Step 3: Insert values
= (100 × 10) ÷ 30

Step 4: Calculate
= 1000 ÷ 30
= 33.3

Step 5: Round to nearest whole number
= 33 gtt/min

A. The client with a respiratory problem expresses interest in smoking cessation, but the nurse waits to put in a consult until the next day. B. The client with pneumonia develops a fever of 101.9°F (38.8 °C), and the nurse does not notify the health care provider. C. The client with chest pain develops pain while ambulating in the hall; the nurse immediately has the client sit down, checks HR and blood pressure, then notifies the provider. D. The client with an altered level of consciousness experiences a fall while trying to go to the bathroom alone. The nurse first assesses the patient, then reports the Incident.

Correct Answer is B

Explanation

Failure to rescue reflects systemic inefficiency and clinical oversight where healthcare providers fail to recognize or act upon impending deterioration. This phenomenon correlates with mortality rates, emphasizing the necessity of early detection of physiological instability and rapid intervention to prevent adverse outcomes.

Rationale:

A. Delaying a smoking cessation consult is a missed opportunity for preventative health, but it does not constitute failure to rescue. Failure to rescue specifically refers to life-threatening clinical complications that occur while a patient is under professional medical supervision.

B. Failing to notify a provider about a high fever in a pneumonia patient illustrates clinical negligence. Ignoring signs of sepsis progression or worsening infection prevents timely intervention, directly leading to a failure to rescue from a potentially fatal condition.

C. Immediately assisting a client with chest pain and assessing hemodynamic status demonstrates competent clinical judgment. This proactive response facilitates early intervention, which is the exact opposite of failure to rescue, as the nurse actively manages the acute event.

D. While a fall indicates a lapse in safety protocols, reporting the incident and assessing the client after the fact is standard procedure. Failure to rescue typically involves missing clinical cues that lead to death or major permanent disability from complications.

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A nurse is contributing to the development of a fall-prevention policy for clients with dementia. Which source of information should the nurse identify as the primary guideline for the creation of the policy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["33"]

Explanation

The nurse is providing care for four clients. Which best provides an example of the clinical judgment term failure to rescue (FTR)?

Correct Answer is B

Explanation

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