Examkin

Soru

Zorluk: KolayAccident, Error, and Injury Prevention

A nurse is admitting a client who has a high risk for falls due to frequent episodes of orthostatic hypotension. Which of the following safety measures should the nurse implement? Select all that apply.

  1. Place the client's bed in the lowest position.Cevap
  2. Ensure the client's call light is placed within reach.Cevap
  3. Instruct the client to rise slowly from a lying to a sitting position.Cevap
  4. D
    Provide the client with smooth-soled slippers for ambulation.
  5. E
    Keep all four bed rails raised while the client is resting.
  6. F
    Delegate the initial fall risk assessment to the unlicensed assistive personnel (UAP).

Cevap

The correct safety measures are placing the bed in the lowest position, ensuring the call light is within reach, and instructing the client to rise slowly.
Standard safety precautions for fall prevention require keeping the bed in the lowest position and ensuring the call light is within easy reach so the client can request help. Furthermore, for a client with orthostatic hypotension, providing instructions to rise slowly is a critical targeted intervention that allows blood pressure to stabilize, preventing dizziness and subsequent falls.

Adım Adım Çözüm

1
Identify the client's primary safety risk factor.
The client has a high risk for falls specifically related to orthostatic hypotension.
Understanding the specific cause of the fall risk ensures interventions are targeted and appropriate.
2
Select interventions that create a safe environment and directly address position changes.
Lowering the bed, providing the call light, and teaching the client to change positions slowly are identified as appropriate actions.
These are standard, evidence-based nursing interventions that protect the client while directly addressing the physiological issue of orthostatic hypotension.
3
Exclude inappropriate, unsafe, or out-of-scope interventions.
Using smooth-soled slippers, raising four side rails, and delegating the initial assessment are excluded.
These actions either increase injury risk, represent inappropriate use of restraints, or violate delegation guidelines.

Anahtar Kavram

Fall Prevention and Safety Precautions
Bu soruyu puanla

Konular

Accident, Error, and Injury Prevention

Bu konudan daha fazla soru