The nurse is caring for a group of patients on the medical-surgical unit.The most important action the nurse can take in preventing falls is:

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Perhaps the single most important thing a nurse can do to prevent falls is to identify those who are at risk for falls.This should be done on the initial admitting assessment and throughout the patient's hospitalization.Once a fall risk is identified,there are many mechanisms put in place to alert others to fall risk.Mechanisms such as special colored armbands and placing signs on the patient's door are commonly used.The use of siderails has not been shown to prevent falls,as patients commonly climb over them.Use of wrist restraints on a confused or combative patient may be helpful in preventing falls; however,restraints are used as a last resort.

The Nurse Is Caring for a Group of Patients on the Medical-Surgical