The nurse is implementing interventions to reduce the number of falls in the health care facility.
What action is best for the nurse to implement?

Provide non-slip footwear to patients during their stay.

Keep the bed in high position to allow for ease of care.

Institute a policy requiring a sitter for all patients above the age of 60.

Avoid using a night light in the room to promote sleep.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Providing non-slip footwear to patients during their stay is a good preventive measure, but it only addresses the risk of falls related to slippery floors. It does not address the overall fall risk, especially for elderly patients who may need constant supervision and assistance.

Choice B rationale:

Keeping the bed in a high position for ease of care might seem practical, but it increases the risk of falls when the patient attempts to get out of bed. Lowering the bed reduces the risk of injury if a fall occurs and is a more appropriate intervention.

Choice C rationale:

Instituting a policy requiring a sitter for all patients above the age of 60 is the best option among the choices provided. Elderly patients are at a higher risk of falls due to various factors such as weakened muscles, balance issues, and medication side effects. Having a dedicated sitter ensures constant supervision, timely assistance, and prompt intervention if the patient attempts to get out of bed, significantly reducing the risk of falls.

Choice D rationale:

Avoiding the use of a night light in the room to promote sleep is not a recommended intervention. While promoting sleep is essential for overall patient well-being, patient safety should always be the priority. Providing adequate lighting, especially at night, reduces the risk of falls and other accidents.

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Correct Answer is C

Explanation

Choice C rationale:

When a patient has been bedridden for an extended period, such as two weeks, the nurse expects to find atrophy of leg muscles due to immobility. Lack of physical activity leads to muscle wasting, which can result in decreased muscle mass and strength. This condition is reversible with proper rehabilitation and exercise.

Choice A rationale:

Decreased respiratory rate due to stronger lungs is not a typical effect of immobility. Immobility can lead to decreased lung expansion and increased risk of respiratory complications, such as pneumonia.

Choice B rationale:

Increased urinary output due to enhanced bladder muscle tone is not a direct effect of immobility. Immobility can affect urinary elimination, but it is more likely to cause urinary retention due to decreased mobility and inability to reach the bathroom independently.

Choice D rationale:

Frequent bowel movements due to increased peristalsis are not expected with immobility. Immobility often leads to slowed peristalsis, which can result in constipation rather than frequent bowel movements.

A. The nurse verifies the recipient's fax number before faxing private patient information. B. The nurse documents the patient assessment using objective data. C. The nurse posts the obituary of a patient on social media. D. The nurse discards copies of patient information into the regular trash bin. E. The nurse accesses the nurse's own health record via computer.

Correct Answer is ["C","D"]

Explanation

Choice A rationale:

The nurse verifies the recipient's fax number before faxing private patient information. This action is appropriate and ensures that patient information is sent to the correct recipient, maintaining patient confidentiality and privacy. Verifying recipient information is a standard practice in healthcare settings to prevent data breaches.

Choice B rationale:

The nurse documents the patient assessment using objective data. This action is appropriate and follows evidence-based practice guidelines. Objective data are measurable and observable, providing a clear picture of the patient's condition. Objective documentation enhances communication among healthcare providers and ensures accurate representation of the patient's status.

Choice C rationale:

The nurse posts the obituary of a patient on social media. This action is highly inappropriate and unethical. It breaches patient confidentiality and privacy, violating the Health Insurance Portability and Accountability Act (HIPAA) regulations. Sharing patient information, especially sensitive details like an obituary, on social media platforms is a serious violation of privacy and can lead to legal consequences.

Choice D rationale:

The nurse discards copies of patient information into the regular trash bin. This action is inappropriate and violates patient confidentiality. Proper disposal of patient information is crucial to protect patient privacy and comply with regulations. Patient documents should be shredded or disposed of in designated secure bins to prevent unauthorized access to sensitive information.

Choice E rationale:

The nurse accesses the nurse's own health record via computer. This action is inappropriate unless there is a legitimate reason related to patient care. Accessing one's own health record without a valid purpose is a breach of patient privacy and can lead to disciplinary actions. Healthcare professionals should only access patient records when necessary for providing care and treatment.

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The nurse is implementing interventions to reduce the number of falls in the health care facility.What action is best for the nurse to implement?

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The nurse is implementing interventions to reduce the number of falls in the health care facility.
What action is best for the nurse to implement?