{"id":211347,"date":"2025-05-03T18:46:07","date_gmt":"2025-05-03T18:46:07","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=211347"},"modified":"2025-05-03T18:46:10","modified_gmt":"2025-05-03T18:46:10","slug":"a-nurse-in-a-long-term-care-facility-is-assisting-with-the-admission-of-several-clients","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2025\/05\/03\/a-nurse-in-a-long-term-care-facility-is-assisting-with-the-admission-of-several-clients\/","title":{"rendered":"A nurse in a long-term care facility is assisting with the admission of several clients."},"content":{"rendered":"\n

A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?<\/p>\n\n\n\n

Provide assistance with ambulation when indicated.
Determine the mobility status of each client.
Maintain the side rails of each bed in the raised position.
Plan a fall prevention program for clients at risk.<\/p>\n\n\n\n

The Correct Answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n

The correct answer is: Determine the mobility status of each client.<\/strong><\/p>\n\n\n\n

\n\n\n\n

Rationale:<\/strong><\/h3>\n\n\n\n

When prioritizing actions to prevent falls in hospitalized or long-term care clients, the first step is assessment<\/strong>. In this case, determining each client\u2019s mobility status<\/strong> is critical because it provides the foundation for planning safe care and interventions. Understanding a client’s ability to move independently, use assistive devices, bear weight, or maintain balance helps the nurse identify those at high risk for falling and take appropriate, individualized action.<\/p>\n\n\n\n

\n\n\n\n

Why the other options are not the first step:<\/strong><\/h3>\n\n\n\n
    \n
  • Provide assistance with ambulation when indicated:<\/strong><\/li>\n\n\n\n
  • This is an important fall prevention strategy<\/strong>, but it should come after<\/strong> assessing mobility. Without knowing each client’s ambulation needs or limitations, offering assistance could be either unnecessary or inadequate.<\/li>\n\n\n\n
  • Maintain the side rails of each bed in the raised position:<\/strong><\/li>\n\n\n\n
  • While side rails might seem like a fall prevention strategy, raising all side rails for every client is not recommended<\/strong>. In fact, this can increase fall risk<\/strong>, especially for confused or agitated clients who might try to climb over them. This practice should be based on individual needs and not applied universally.<\/li>\n\n\n\n
  • Plan a fall prevention program for clients at risk:<\/strong><\/li>\n\n\n\n
  • This is a critical component<\/strong> of fall prevention but can only be developed after<\/strong> the nurse identifies who is at risk through assessment. Therefore, planning comes after<\/strong> determining mobility status.<\/li>\n<\/ul>\n\n\n\n
    \n\n\n\n

    Conclusion:<\/strong><\/h3>\n\n\n\n

    The first step<\/strong> in fall prevention during client admissions is to gather data<\/strong>\u2014specifically, to determine the mobility status<\/strong> of each client. This ensures that subsequent actions like ambulation assistance or individualized fall prevention programs are safe, appropriate, and effective.<\/p>\n\n\n\n

    \n","protected":false},"excerpt":{"rendered":"

    A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? Provide assistance with ambulation when indicated.Determine the mobility status of each client.Maintain the side rails of each bed in the raised position.Plan a fall […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-211347","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/211347","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=211347"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/211347\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=211347"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=211347"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=211347"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}