NCLEX-RN

Category - Safety

A nurse is admitting an elderly client with Alzheimer’s disease to the medical ward. What important guidelines should the nurse apply to prevent falls during their shift?
  1. Upon admission, orient the client to their surroundings.
  2. Explain the call system or call light, and keep the call light near the client.
  3. Keep the hospital bed in the lowest level and lock the wheels.
  4. Provide non-skid footwear.
Explanation
Answer: C - To prevent falls the nurse should keep the hospital bed in the lowest level and the wheels should be locked. Orienting to the surroundings and explaining the call system may not be effective measures for this particular client. Instead of providing non-skid footwear, the nurse should closely supervise the client and anticipate their needs to avoid accidents. Objects frequently used by the client should be placed near the bed or on the overbed table to avoid overreaching.
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