Question

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? a. Check on the patient once a shift. b. Encourage visitors in the early evening. c. Place all four side rails in the "up" position. d. Keep the patient on fall risk until discharge.

Answer 1

The nurse will take the action of placing all four side rails in the "up" position as a preventive measure to keep the patient from falling out of the bed.

Step-by-step explanation:

The nurse will take the action of placing all four side rails in the "up" position. This is done as a preventive measure to keep the patient from falling out of the bed. However, using all four side rails can also present a risk of entrapment, so the nurse would need to assess the patient for the need to use them.

Checking on the patient once a shift may not be sufficient to ensure their safety, so it would be important for the nurse to check on the patient more frequently.

Encouraging visitors in the early evening does not directly address fall precautions. Visitors should be educated about the importance of following fall prevention measures, such as not leaving items on the floor that could cause the patient to trip.

Keeping the patient on fall risk until discharge is important, but it is not the action the nurse will take to address fall precautions directly.

Learn more about Fall precautions