A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

Install a bed exit sensor pad at the foot of the client's bed.

Encourage the client to ambulate in compression stockings.

Raise all four side rails for the client at bedtime.

Place a raised toilet seat in the client's bathroom.

Answer and Explanation

The Correct Answer is D

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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Correct Answer is C

Explanation

A. Assume the family does not have access to regular medical treatment. Assumptions can lead to misunderstandings and are not based on individualized assessment.
B. Offer the family basic financial advice when needed. While helpful, it is not the primary role of the nurse and should be done with appropriate referrals.
C. Learn about the family's culture prior to the assessment. Understanding the family's culture helps provide culturally competent care and improves communication and trust.
D. Avoid discussing the family's health practices. Discussing health practices is crucial for understanding and addressing the family's needs effectively.

A. Potassium chloride 20 mEq oral every other day B. Regular insulin 2U SQ before meals C. Vancomycin 1 g IV piggyback every 8 hr D. Ativan 0.5 mg IV every 2 hr as needed for anxiety

Correct Answer is B

Explanation

A. Potassium chloride 20 mEq oral every other day This statement does not contain any error-prone abbreviations.
B. Regular insulin 2U SQ before meals The abbreviation "U" for units can be mistaken for "0" or "4", leading to dosing errors. The correct term is "units".
C. Vancomycin 1 g IV piggyback every 8 hr This statement does not contain any error-prone abbreviations.
D. Ativan 0.5 mg IV every 2 hr as needed for anxiety This statement does not contain any error-prone abbreviations.

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