The nurse is caring for a group of patients on the medical-surgical unit. The most important action the nurse can take in preventing falls is:
a. Use two siderails for each patient's bed
b. Place a fall risk sign on the front of the patient's door
c. Identify those patients who are at risk for falls
d. Use wrist restraints for any confused or combative patient
C
Perhaps the single most important thing a nurse can do to prevent falls is to identify those who are at risk for falls. This should be done on the initial admitting assessment and throughout the patient's hospitalization. Once a fall risk is identified, there are many mechanisms put in place to alert others to fall risk. Mechanisms such as special colored armbands and placing signs on the patient's door are commonly used. The use of siderails has not been shown to prevent falls, as patients commonly climb over them. Use of wrist restraints on a confused or combative patient may be helpful in preventing falls; however, restraints are used as a last resort.
You might also like to view...
The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The client speaks very little English and is a smoker. Which action would be the most beneficial for this client?
A) Have the adult child of the client translate during the assessment process B) Encourage aerobic activity C) Encourage the client to write down questions prior to seeing the healthcare provider D) Obtain educational materials about smoking cessation written in Spanish.
Which of the following should the nurse include in the examination of the patient's cranial nerves and extraocular eye muscles?
a. red reflex c. disc characteristics b. macular characteristics d. six cardinal fields of gaze
A nursing student is studying public health. She learns that, according to C.E.A. Winslow's definition, some of the goals of public health are disease prevention, promoting health, control of communicable infections, and ____
A. Risk assessment for disease B. Birth control C. Education on personal hygiene D. Governmental safety regulations
Which of the following was initiated to help ensure that the quality and safety of care was not compromised?
a. CQI c. TEFRA b. HSA d. PPO