Difficulty: Medium
Average Score: 72%
Simulated
The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include:
Correct answer
A,C,E
Rationale
Correct Answer: A, C, E
Rationale:
A: Placing a high risk for falls armband on the patient alerts all staff of the patient's fall risk status.
C: Keeping the bed in the lowest position reduces the risk of injury if the patient falls out of bed.
E: Maintaining the call light within reach allows the patient to easily call for assistance to prevent falls.
Summary:
B: Checking on the patient once a shift is not sufficient for fall prevention as it may not be timely.
D: Placing all four side rails in the 'up' position can lead to patient restraint, which is not recommended for fall precautions.
Rationale:
A: Placing a high risk for falls armband on the patient alerts all staff of the patient's fall risk status.
C: Keeping the bed in the lowest position reduces the risk of injury if the patient falls out of bed.
E: Maintaining the call light within reach allows the patient to easily call for assistance to prevent falls.
Summary:
B: Checking on the patient once a shift is not sufficient for fall prevention as it may not be timely.
D: Placing all four side rails in the 'up' position can lead to patient restraint, which is not recommended for fall precautions.