A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
A)UAP has attached a bed alarm to the client's gown and bed
B)UAP has been making hourly rounds on the client
C)UAP has lowered the bed and raised all 4 side rails
D)UAP has placed a fall risk ID bracelet on the client's wrist

Question

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls.  The nurse shares this information with the unlicensed assistive personnel (UAP).  Which finding by the nurse requires intervention?
A)UAP has attached a bed alarm to the client's gown and bed
B)UAP has been making hourly rounds on the client
C)UAP has lowered the bed and raised all 4 side rails
D)UAP has placed a fall risk ID bracelet on the client's wrist

Quizplus · Accepted Answer

Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate. (Option A) Placing a bed alarm would be an appropriate intervention for this client. (Option B) Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted. (Option D) Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls. Educational objective: The nurse should ensure that multiple interventions are put in place for the client at high risk for falls. These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client.

A Nurse Has Received Report from the Off-Going Shift That