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. 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.

A. Placing a sign on the client's room door indicating fall risk. B. Encouraging the client to use the call bell for assistance. C. Providing a nonskid mat on the floor beside the client's bed. D. Ensuring the client has adequate lighting in the room.

Correct Answer is B

Explanation

d. Ensuring the client has adequate lighting in the room.

Answer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.

Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.

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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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