The nurse is caring for an older adult client who is at risk for falls. Which action by the nurse is most appropriate?

Providing the client with a walker for ambulation.

Encouraging the client to perform regular exercise.

Placing the client in restraints to prevent wandering.

Administering sedative medications to promote rest.

Answer and Explanation

The Correct Answer is A

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Correct Answer is A

Explanation

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.

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 an older adult client who is at risk for falls. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

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