The night nurse reports that, during the night, Mrs. Sherman fell on the floor at the foot of her bed. She was uninjured but was incontinent of urine and complained that she "could not get to the bathroom because of the side rails being up
" What is the most appropriate nursing intervention to prevent Mrs. Sherman from falling again?
a. Put the side rails down during the night
b. Place a commode next to Mrs. Sherman
c. Apply a soft waist restraint on Mrs. Sherman at night
d. Initiate a toileting program for Mrs. Sherman
D
Toileting programs can reduce the incidence of an older adult's attempting to go into the bathroom without assistance. Removing side rails (response A) and using restraints (response C) are not good choices. Commonly, older adults who are restrained have an increased incidence of incontinence. Lowering the side rails and placing a commode at the bedside (response B) would improve the older adult's access to toileting facilities but would not decrease the older adult's risk of falling.
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