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Question

Difficulty: EasyAccident, Error, and Injury Prevention

A practical nurse is providing care for a client who has right-sided weakness following a stroke and is at a high risk for falls. The nurse is preparing to leave the room after assisting the client into bed. Which action should the nurse take to prevent an accidental fall?

  1. Place the call light and personal items within easy reach on the client's unaffected left side.Answer
  2. B
    Raise all four side rails on the bed to prevent the client from attempting to get up unassisted.
  3. C
    Delegate the assessment of the client's ongoing fall risk to the unlicensed assistive personnel (UAP).
  4. D
    Administer a prescribed as-needed sedative to encourage the client to sleep through the night.

Answer

Place the call light and personal items within easy reach on the client's unaffected left side.
Placing the call light and essential items on the client's unaffected (strong) side ensures they can safely access what they need and easily call for help. This proactive, least-restrictive intervention directly mitigates the fall risk associated with the client's right-sided weakness.

Step-by-Step Solution

1
Identify the client's specific physical limitations and safety risks.
The client has right-sided weakness and a high fall risk.
Understanding the client's deficits dictates which safety interventions will be most effective.
2
Evaluate the proposed interventions against safety standards and the nursing scope of practice.
Using four side rails or sedatives are inappropriate restraints; delegating assessment is out of scope.
Nurses must use the least restrictive measures to ensure safety while adhering to legal and ethical guidelines.
3
Select the most appropriate, least restrictive proactive safety measure.
Positioning items on the strong side empowers the client and minimizes the need for unsafe reaching.
This directly addresses the client's physical deficit while maintaining a safe environment without utilizing restraints.

Key Concept

Fall Prevention and Restraint Alternatives
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Topics

Accident, Error, and Injury Prevention

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