What is the nurse's first priority when caring for a client with a history of falls?
1. Placing the call light for easy access.
B. Keeping the bed in the lowest possible position.
C. Instructing the client not to get out of bed without assistance.
D. Keeping the bedpan available so that the client doesn t have to get out of bed.
The answer to this is letter B. The patient has a tendency to fall. Making the bed lower will reduce the chances that the patient will get hurt whenever he falls from the bed. It is very natural for nurses to try to instruct patients about the things that they can and cannot do but most patients will not readily follow the orders of their nurses and doctors.
This means that even if the patient is told not to get out of bed, he will most likely do what he wants. Putting the bedpan is not really necessary as this is not the only reason why the patient would like to get out of bed. At times, this may be completely unnecessary especially if the patient will not fall anyway.
Keeping the bed in the lowest possible position.-rationale: keeping the bed at the lowest possible position is the first priority for clients at risk for falling. keeping the call light easily accessible is important but isnt a top priority. instructing the client not to get out of bed may not effectively prevent falls for example, if the client is confused. even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. the client may not require a bedpan. client needs category: safe, effective care environment client needs subcategory: safety and infection control cognitive level: application reference: craven, r.f., and hirnle, c.j. fundamentals of nursing: human health and function, 5th ed. philadelphia: lippincott williams & wilkins, 2007, p. 688.