The nurse is caring for a client on a medical-surgical unit. Which intervention is most important for preventing falls in this client population?

Providing a bedside commode for toileting needs

Placing the client in a private room near the nurses' station.

Implementing hourly rounding to assess the client's needs.

Educating the client on proper use of assistive devices.

Answer and Explanation

The Correct Answer is C

Answer: c. Implementing hourly rounding to assess the client's needs. Explanation: Implementing hourlyrounding to assess the client's needs is the most important intervention for preventing falls in a medical-surgical unit. Regular rounding allows the nurse to monitor the client's condition, address any immediate needs, and provide assistance with mobility or other activities, reducing the risk of falls.

Incorrect choices: a. Providing a bedside commode for toileting needs is important for promoting safe toileting, but it does not address the overall risk of falls. b. Placing the client in a private room near the nurses' station may enhance surveillance, but it does not actively prevent falls. d. Educating the client on proper use of assistive devices is essential, but it is not the most critical intervention for fall prevention in the medical-surgical unit setting.

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Correct Answer is A

Explanation

Answer: a. "I will make sure to wear my eyeglasses all the time." Explanation: The statement "I will make sure to wear my eyeglasses all the time" indicates a need for further education on fall prevention. While wearing eyeglasses can improve vision, it is not adirect fall prevention measure. It is important for the client to address other risk factors such as environmental hazards, balance, and mobility.

Incorrect choices: b. "I will use the handrails when going up and down the stairs." This statement demonstrates an understanding of using handrails for support and stability while navigating stairs, which is an appropriate fall prevention measure. c. "I will ask for help when I need to use the bathroom at night." This statement reflects the client's awareness of the need to seek assistance when necessary, reducing the risk of falls during nighttime bathroom visits. d. "I will keep my room well-lit during the day and night." This statement indicates an understanding of the importance of adequate lighting to enhance visibility and prevent falls in the client's room.

A. Removing tripping hazards from the client's environment. B. Providing the client with nonskid footwear. C. Educating the client on the correct use of handrails. D. Assisting the client with toileting and ambulation.

Correct Answer is A

Explanation

Answer: a. Removing tripping hazards from the client's environment. Explanation: Removing tripping hazards from the client's environment is the most important intervention for preventing falls. It helps create a safe and hazard-free environment, reducing the risk of accidental falls.

Incorrect choices: b. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls but may not address all potential fall risks. c. Educating the client on the correct use of handrails is essential, but it may not be the most critical intervention compared to removing environmental hazards. d. Assisting the client with toileting and ambulation is important, but it focuses on direct assistance rather than eliminating hazards from the environment.

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The nurse is caring for a client on a medical-surgical unit. Which intervention is most important for preventing falls in this client population?

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