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 ["B","E"]
Explanation
Choice A rationale:
Using correction fluid to correct an erroneous written entry is not appropriate as it can obscure the information and raise questions about the accuracy of the documentation. It is better to strike through the error with a single line, write the correct information, and sign and date the correction.
Choice B rationale:
Documenting changes in the patient's status is crucial for ensuring continuity of care and keeping all healthcare providers informed about the patient's condition.
Choice C rationale:
Leaving a blank line for the charge nurse to add additional documentation is not recommended. Each entry should be complete and include all relevant information at the time of documentation.
Choice D rationale:
Planning to finish charting the procedure after returning from a break is not appropriate. Charting should be done in real-time to ensure accuracy and timeliness of the information.
Choice E rationale:
Charting using military (24-hour) time is appropriate as it reduces confusion and ensures a standardized way of documenting time across different healthcare settings.
Correct Answer is
Explanation
Choice A rationale:
Making sure the consent is signed and in the patient's chart in a timely manner is an important step in the consent process. However, the most appropriate action for the nurse in this situation is to verify the necessity of the surgical procedure before placing the consent in the chart. This is crucial to ensure that the patient fully understands the procedure they are consenting to and that it is medically necessary. Verifying the necessity of the surgical procedure helps in preventing unnecessary procedures, promoting patient safety, and adhering to ethical principles.
Choice B rationale:
Verifying the necessity of the surgical procedure before placing the consent in the chart is the most appropriate action for the newly licensed nurse. This step ensures that the procedure is medically necessary, aligns with the patient's condition, and promotes informed decision-making. By confirming the necessity, the nurse upholds the principle of beneficence, ensuring the patient's well-being, and autonomy, allowing the patient to make informed decisions about their healthcare.
Choice C rationale:
Asking a family member to translate the consent into the language the patient understands might be helpful in improving the patient's understanding of the procedure. However, the primary concern in this situation is verifying the necessity of the surgical procedure. While communication is essential, it does not address the core issue of confirming the medical need for the surgery.
Choice D rationale:
Explaining the risks and benefits of the surgical procedure prior to getting a signature is a vital step in the consent process. However, the question specifically asks for the most appropriate action, which is to verify the necessity of the procedure. Explaining the risks and benefits is an important follow-up step after ensuring the procedure's necessity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.