The nurse is caring for a client who is at risk for falls. Which action by the nurse is most appropriate to prevent falls?

Keeping the client's bed in the lowest position.

Using bed rails to restrict the client's movement.

Providing the client with nonskid footwear.

Administering sedative medications at bedtime.

Answer and Explanation

The Correct Answer is A

Answer: a. Keeping the client's bed in the lowest position. Explanation: Keeping the client's bed in the lowest position is the most appropriate action to prevent falls. A low bed height reduces the risk of injury if the client accidentally falls out of bed.

Incorrect choices: b. Using bed rails to restrict the client's movement is not recommended as it can increase the risk of entrapment or injury. Bed rails should be used judiciously and with caution. c. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls, but it is not the most crucial intervention in this scenario. d. Administering sedative medications at bedtime increases the risk of falls by affecting the client's balance and alertness. Sedatives should be used sparingly and only when necessary.

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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. Providing a bedside commode for toileting needs B. Placing the client in a private room near the nurses' station. C. Implementing hourly rounding to assess the client's needs. D. Educating the client on proper use of assistive devices.

Correct Answer is C

Explanation

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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The nurse is caring for a client who is at risk for falls. Which action by the nurse is most appropriate to prevent falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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