Difficulty: Medium
Average Score: 62%
Simulated
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?
Correct answer
D
Rationale
The correct answer is D: Keep the patient on fall risk until discharge. This is because fall precautions should be maintained throughout the patient's stay to ensure their safety. Checking on the patient once a shift (A) may not be sufficient to prevent falls. Encouraging visitors in the early evening (B) could distract the patient and increase fall risk. Placing all four side rails in the 'up' position (C) can lead to entrapment or injury. Therefore, the best practice is to keep the patient on fall risk until discharge to maintain a high level of vigilance and prevent falls effectively.