A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)
Ensure the client wears nonskid slippers when walking around the house.
Attach full-length side rails to the client's bed.
Install a raised toilet seat in the client's bathroom.
Encourage an annual review of the medications the client is taking.
Place throw rugs on uncarpeted floors in the client's home.
Correct Answer : A,C,D
Ensure the client wears nonskid slippers when walking around the house.
Explanation: Nonskid slippers provide better traction and stability, reducing the risk of slipping.
B.Attach full-length side rails to the client's bed.
Explanation: Side rails can pose a risk of entrapment and may not prevent falls. The use of side rails is associated with safety concerns, and their use should be carefully evaluated.
C.Install a raised toilet seat in the client's bathroom.
Explanation: A raised toilet seat makes it easier for the client to sit down and stand up, reducing the risk of falls in the bathroom.
D.Encourage an annual review of the medications the client is taking.
Explanation: Medication reviews help identify drugs that may increase the risk of falls or interactions that could affect balance or cognitive function.
E.Place throw rugs on uncarpeted floors in the client's home.
Explanation: Throw rugs can be tripping hazards, especially for older adults with mobility issues. It's safer to have clear, unobstructed pathways in the home.
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Related Questions
Correct Answer is A
Explanation
This client has undergone a paracentesis for ascites, and since it was done 4 hours ago, they are likely stable and can be considered for discharge.
The client who is 6 hours postoperative following a hip arthroplasty may still require close monitoring and postoperative care. Discharging a postoperative client too early could lead to complications.
The client with a blood glucose level of 380 mg/dL receiving insulin via IV infusion requires ongoing monitoring and management of their diabetes. Discharging this client during an external disaster may not be appropriate due to the need for continued medical intervention.
The client with pneumonia receiving 100% oxygen via a nonrebreather mask likely requires continued medical attention and monitoring. Discharging a client with pneumonia who requires high-flow oxygen can pose risks to their respiratory status.
Correct Answer is B
Explanation
A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.
B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.
C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.
D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.
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