Fall prevention
Falls are among the most common injuries in hospitals, especially in older adults.
| Intervention | Why |
|---|---|
| Bed in lowest position, wheels locked | Reduces injury if the client gets up |
| Call light, phone, water within reach | Reduces unassisted reaching and walking |
| Scheduled toileting and regular rounding | Urgency is a common reason for falls |
| Nonskid footwear, night light, clear path | Safer walking |
| Bed or chair alarms per policy | Alerts staff early |
Full side rails up can count as a restraint and can increase injury from climbing; follow policy.
Restraints
Restraints carry real risks (injury, strangulation, pressure injury, agitation) and are tightly regulated.
| Rule | Detail |
|---|---|
| Order | Time-limited order from an authorized provider; never as needed (PRN) |
| Application | Fit allows about two fingers under the strap; tie to the bed frame with a quick-release knot |
| Monitoring | Circulation, skin, sensation, breathing, hydration, nutrition, toileting, and comfort at policy intervals |
| Release | Remove as soon as the client is safe; reassess regularly |
| Documentation | Behavior, alternatives tried, monitoring, and release |
Violent or self-destructive behavior has stricter time limits and evaluation requirements under federal rules and facility policy.
Fire and environmental safety
Fire response follows two memorized sequences.
- Extinguisher use (PASS): Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side.
- Oxygen safety: no open flames or smoking; keep oxygen away from heat.
- Electrical safety: do not use frayed cords; report damaged equipment.
Seizure precautions and safe body mechanics
Two more safety topics that recur on the exam.
| During a seizure | After a seizure |
|---|---|
| Stay with the client; call for help | Side-lying to drain secretions |
| Protect the head; move hazards away | Assess airway, breathing, oxygen saturation |
| Time the seizure; note characteristics | Reorient; check for injury |
| Do not restrain or put anything in the mouth | Document onset, duration, and behavior |
A seizure lasting 5 minutes or longer, or repeated seizures without recovery, is status epilepticus — an emergency.
- Lift with the legs, keep loads close to the body, avoid twisting; use lift equipment and get help.
- Raise the bed to working height for care, then lower it.
NGN-style case
Choosing the least restrictive safe action.
An older adult with new postoperative delirium keeps trying to get out of bed and pulls at the IV. The nurse finds the client sitting on the edge of the bed. What should the nurse do first?
- Recognize cues: new confusion, fall risk, IV pulling.
- Analyze: delirium has causes to look for (pain, hypoxia, infection, urinary retention, drugs).
- Act first on immediate safety with least restrictive measures: stay with the client, help them back to bed, lower the bed, check needs such as toileting.
- Notify the provider about the delirium; consider a sitter, covering the IV, and reorientation before any restraint.
Answer. Stay with the client, address immediate needs and safety with less restrictive measures, and notify the provider about the new confusion.