Editing Fundamentals of Nursing – RN Practice Questions (section)

==Question 13==
Which actions should the nurse take when a confused patient at high risk for falls repeatedly attempts to climb out of bed? '''Select all that apply.'''
# Move the patient to a room near the nurses' station for closer observation.
# Raise all four side rails to keep the patient in bed.
# Implement hourly rounding that addresses pain, position, toileting needs, and possessions.
# Place the bed in the lowest position with the wheels locked and use a bed exit alarm.
# Apply soft wrist restraints as needed for restlessness.
# Ensure nonskid footwear and adequate lighting including a night light.

'''Answer:''' 1, 3, 4, and 6.

''Rationale:'' Least restrictive interventions come first. Increased visibility, hourly rounding that meets the underlying needs driving the behavior, a low locked bed with an exit alarm, and environmental measures are all evidence based fall precautions. Option 2 is incorrect because four raised side rails constitute a restraint and also increase injury severity if the patient climbs over them. Option 5 is incorrect on two counts: restraints are a last resort only after less restrictive measures fail, and restraints may never be prescribed on an as needed basis.