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Difficulty: EasyAccident, Error, and Injury Prevention

A client with generalized weakness is admitted to a medical unit. The admission screening indicates the client is at high risk for falling. Which standard safety interventions should the nurse implement? Select all that apply.

  1. Keep the hospital bed in the lowest possible position.Answer
  2. Place the call bell and frequently used items within the client's reach.Answer
  3. C
    Keep the upper and lower bed rails raised on both sides of the bed.
  4. D
    Explain to the family that frequent falls are an expected part of the normal aging process.
  5. Ensure the client wears non-slip footwear before standing or walking.Answer

Answer

The nurse should keep the bed in the lowest position, keep personal items within reach, and ensure the use of non-slip footwear.
The correct interventions focus on modifying the client's environment to maximize safety without restricting their freedom of movement. Keeping the bed low, providing non-slip footwear, and keeping essential items within reach are foundational components of a universal fall prevention bundle.

Step-by-Step Solution

1
Identify the primary safety risk presented in the scenario.
The client has generalized weakness and is at a high risk for falling.
Establishing the risk profile determines which safety protocols must be activated.
2
Evaluate each proposed intervention against standard safety and restraint policies.
Low bed position, reachable items, and non-slip footwear are safe and appropriate. Raising all side rails is an unwarranted restraint, and normalizing falls is factually incorrect.
Nurses must implement evidence-based fall precautions while avoiding unwarranted restraints.

Key Concept

Standard Fall Prevention Precautions
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Topics

Accident, Error, and Injury Prevention

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