The registered nurse preceptor plans to teach a new graduate registered nurse about nursing actions to prevent falls. Which actions should the preceptor include? Select All That Apply.
Clean up spills immediately.
Remind clients to call for help before getting out of bed or a chair.
Teach clients to use grab bars when walking in the hall without assistive devices.
Monitor the client's activities and behavior as often as possible.
Help the incontinent client to the toilet at least once each shift.
Teach clients and families about fall prevention to become safety partners.
Remind the client to wear glasses and a hearing aid.
Correct Answer : A,B,D,F,G
Fall prevention in clinical settings requires a multifaceted strategy focused on identifying and mitigating environmental and physiological hazards. High-risk populations often exhibit sensory impairment or gait instability, necessitating proactive surveillance to maintain a safe therapeutic environment. Successful mitigation relies on a collaborative partnership between the interdisciplinary team, the client, and their support system to ensure consistent adherence to safety protocols.
Rationale:
A. Liquid on floor surfaces significantly reduces the coefficient of friction, creating an immediate slip hazard for ambulatory clients. Rapid removal of moisture is a fundamental environmental control measure to prevent orthopedic injuries or head trauma. This action must be performed immediately to maintain spatial safety in high-traffic patient care areas.
B. Encouraging clients to utilize the call system ensures that supervised mobility is maintained for those with impaired balance or strength. This practice prevents unassisted transfers that frequently lead to mechanical falls when the client overestimates their physical capacity. Consistent reinforcement of this habit is a key preventative intervention for inpatient safety.
C. Hallway grab bars are designed as static supports for stability while standing or in the bathroom, not as mobility aids for ambulation. Clients should be taught to use dynamic equipment like walkers or canes if they require support while walking long distances. Relying on wall-mounted bars for walking can lead to postural instability and falls.
D. Frequent observation allows the nurse to identify early indicators of restlessness, confusion, or unsafe behaviors that precede fall events. Close monitoring facilitates timely intervention when a client attempts to exit the bed without the necessary assistance. Vigilance is particularly crucial for clients with cognitive deficits or pharmacological-induced sedation.
E. Incontinent clients are at high risk for falls due to urinary urgency and the frequent need to ambulate to the bathroom. Assisting a client only once per shift is clinically inadequate to prevent toileting-related accidents and subsequent falls on wet surfaces. Frequent, scheduled toileting rounds are required to meet the client's elimination needs safely.
F. Educating the client and their family fosters a culture of safety awareness and empowers them to identify potential risks. When families understand the rationale behind fall precautions, they are more likely to comply with safety restrictions and alert staff to hazards. This engagement transforms the family into an active safety advocate.
G. Proper use of corrective lenses and hearing amplification is essential for maintaining environmental orientation and depth perception. Sensory deprivation increases the risk of tripping over obstacles or failing to hear auditory warnings from staff or equipment. Ensuring these devices are functional and in use optimizes the client's neurological processing of surroundings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Advance directives facilitate patient autonomy by documenting healthcare preferences before incapacitation. These legal instruments ensure that end-of-life decisions align with the individual's values, particularly during high-acuity surgeries where the risk of losing decision-making capacity is significant.
Rationale:
A. A DNR is a specific medical order signed by a physician, not a comprehensive advance directive. It only addresses cardiopulmonary resuscitation and is too narrow for a client needing broad representation during an upcoming emergency surgery.
B. A living will specifies treatment preferences but is often limited to terminal conditions or persistent vegetative states. In emergency surgery, it may not cover the real-time complexities and fluid clinical decisions required by the surgical team.
C. A durable power of attorney for health care (DPOA-HC) is ideal for surgical patients. It designates a healthcare proxy to make diverse medical decisions if the client is anesthetized or unconscious, ensuring continuous advocacy.
D. A general power of attorney typically grants authority over financial matters and legal transactions. It does not automatically provide the legal right to make medical choices, making it inappropriate for clinical end-of-life or surgical planning.
Correct Answer is D
Explanation
Priority nursing assessment utilizes the ABC framework alongside the identification of life-threatening complications related to anticoagulation therapy. While stable findings are expected in chronic conditions, any new symptom suggestive of internal hemorrhage requires immediate investigation. The charge nurse must prioritize patients based on the risk of hemodynamic instability or sudden physiological collapse to ensure timely medical intervention and prevent adverse outcomes.
Rationale:
A. Nephrotic syndrome is a renal disorder characterized by massive proteinuria and hypoalbuminemia, which often results in the presence of lipids in the urine. Lipiduria is a classic finding in this condition and does not indicate an acute or life-threatening change in the client's status. This client is stable and can be assessed after those with more urgent physiological needs.
B. A pain level of 6 out of 10 in a postoperative client is a distressing symptom that requires pharmacological intervention but is not immediately life-threatening. While the nurse should address the pain to promote recovery and comfort, it does not take precedence over signs of active, occult bleeding. Pain management is a high priority but secondary to circulatory stabilization and safety.
C. A change in the Glasgow Coma Scale from 11 to 13 represents a positive neurological trend and an improvement in the client’s level of consciousness. Since the client is showing signs of recovery rather than deterioration, they do not require the most immediate assessment by the charge nurse. The nurse should continue to monitor for further improvements or any sudden neurological declines.
D. Back pain in a client receiving a heparin infusion is a significant warning sign of retroperitoneal bleeding, a serious complication of systemic anticoagulation. The nurse must assess for signs of hemorrhagic shock and notify the provider immediately to prevent potential cardiovascular collapse or permanent organ damage. This client is the highest priority due to the risk of active internal hemorrhage.
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