A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?
a. Check on the patient once a shift.
b. Encourage visitors in the early evening.
c. Place all four side rails in the "up" position.
d. Keep the patient on fall risk until discharge.
ANS: D
A fall-reduction program includes a fall risk assessment of every patient, conducted on admission and routinely (see hospital policy) until a patient's discharge. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour.
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