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 D

Explanation

the client with a bed alarm system. d. Recommending the use of a cane or walker.

Answer: d. Recommending the use of a cane or walker. Explanation: Recommending the use of a cane or walker is the most appropriate intervention for an older adult client at risk for falls. Assistive devices can provide additional support and stability, helping to maintain balance and reduce the risk of falls.

Incorrect choices: a. Implementing a toileting schedule for the client is important but may not directly address the client's specific fall risk. b. Assessing the client's orthostatic blood pressure is essential for assessing orthostatic hypotension but may not be the most appropriate intervention for addressing fall risk in this scenario. c. Providing the client with a bed alarm system can help alert the nursing staff when the client is attempting to leave the bed, but it does not directly address the client's balance and stability needs.

A. Age over 65 years. B. Use of anticoagulant medications. C. History of previous falls. D. Presence of sensory deficits.

Correct Answer is C

Explanation

Answer: c. History of previous falls. Explanation: A history of previous falls is a significant risk factor for future falls. Clients who have fallen before are more likely to fall again, making it a high-risk factor to consider in fall prevention strategies.

Incorrect choices: a. Age over 65 years is a general risk factor for falls but does not provide as much predictive value as a history of previous falls. b. Use of anticoagulant medications increases the risk of bleeding but does not necessarily indicate a higher risk for falls. d. Presence of sensory deficits, such as visual or auditory impairments, can contribute to fall risk but may not be the highest-risk factor compared to a history of previous falls.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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