What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.
Restrain the patient with a chemical sedative.
Encourage the patient to use grab bars located near toilets and showers.
Place the call light within the patient's reach.
Conduct rounds every four hours.
Apply brakes on wheelchairs and bed.
Correct Answer : B,C,E
Choice A rationale:
Restrain the patient with a chemical sedative. Rationale: Restraints, especially chemical sedatives, should be avoided whenever possible due to the risk of complications and patient distress. Restraints can lead to decreased mobility, increased agitation, and other adverse effects. They should only be used as a last resort and with appropriate justification, such as ensuring patient or staff safety in emergency situations.
Choice B rationale:
Encourage the patient to use grab bars located near toilets and showers. Rationale: Installing grab bars in bathrooms helps prevent falls by providing support and stability for patients, especially those with mobility issues. Encouraging their use promotes patient independence and safety while performing essential activities of daily living.
Choice C rationale:
Place the call light within the patient's reach. Rationale: Placing the call light within the patient's reach ensures that the patient can easily summon assistance when needed. Prompt response to patient requests can prevent accidents and falls by addressing the patient's needs in a timely manner.
Choice D rationale:
Conduct rounds every four hours. Rationale: Conducting regular rounds allows healthcare providers to assess the patient's condition, address their needs, and identify potential fall risks. However, the specific frequency of rounds may vary based on the patient's condition and the healthcare facility's policies. Some patients may require more frequent monitoring, especially if they are at a higher risk of falling.
Choice E rationale:
Apply brakes on wheelchairs and beds. Rationale: Applying brakes on wheelchairs and beds prevents unintended movement, enhancing patient safety and reducing the risk of falls. It ensures that the patient's mobility aids remain stationary, providing stability when the patient is transferring or repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Sharing a positive and educational experience, such as witnessing a lung transplant, demonstrates enthusiasm for the nursing profession and a willingness to learn. It also respects patient privacy as it doesn't disclose any patient's personal information. This kind of post reflects professionalism and genuine interest in the field.
Choice B rationale:
Posting about working with prisoners from the federal prison can be inappropriate and breach patient confidentiality. It is essential to respect patients' privacy and not disclose sensitive information on social media platforms. Sharing such information can lead to legal and ethical consequences.
Choice C rationale:
Posting about having a great day at clinical is a positive and general statement. However, it lacks specific details and does not contribute significantly to the professional image of the nursing student. While it is not necessarily inappropriate, sharing more educational and insightful experiences would be more beneficial.
Choice D rationale:
Posting negative comments about the food at XYZ Hospital is unprofessional and disrespectful. It reflects negatively on the hospital and could damage professional relationships. Additionally, it does not contribute to the nursing student's growth or demonstrate any meaningful engagement with the nursing profession.
Correct Answer is D
No explanation
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