Which of the following fall prevention strategies should the ...

[kaid0807]

Which of the following fall prevention strategies should the nurse perform on all hospitalized patients? (Select all that apply.)
 
  a. Conduct hourly rounds.
  b. Provide the patient regular toileting.
  c. Assess the patient's comfort needs.
  d. Evaluate the effectiveness of pain medication.

Question 2

A patient on PN has gained 4 lbs over a 24-hour period. Given this weight gain, which interpretation by the nurse is most accurate?
 
  a. Increased nutrition from the patient's parenteral infusions
  b. Decreased linoleic acid intake
  c. Increased fluid loss
  d. Fluid retention

[britb2u]

Answer to Question 1

A, B, C
A recent study shows that hourly nurse rounds are an effective strategy for reducing falls. Combining hourly rounds with activities such as regular toileting and assessing the patient's comfort needs manages those factors that often prompt patients to get out of bed without assistance. In the hospital setting, a variety of fall risk factor screening tools are available. Because multiple risk factors for falls are known, no single assessment tool is sensitive and specific for analyzing fall risk.

Answer to Question 2

D
Weight gain greater than 1 lb/day indicates fluid retention. The patient's ideal weight gain is usually between 1 and 2 lb/wk. Weight is an indicator of the patient's nutritional status and determines fluid volume. A nutritional regimen without adequate fatty acids leads to EFAD, characterized by dry, scaly skin, sparse hair growth, impaired wound healing, decreased resistance to stress, increased susceptibility to respiratory tract infection, anemia, thrombocytopenia, and liver function abnormalities.

[kaid0807]

TYSM

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Excellent