Certified Medical-Surgical Registered Nurse Practice Exam

When a nurse leaves a confused elderly patient unattended, resulting in a fall, the nurse's fault lies in not:

1. Properly educating the patient about safety measures

2. Restraining the patient

3. Documenting that she left the patient

4. Arranging for continual care of the patient

The correct answer is: Arranging for continual care of the patient

The core responsibility of a nurse is to ensure the safety and well-being of patients, particularly those who are confused or at a high risk of falling. In this scenario, the nurse's fault lies in not arranging for continual care of the patient. When a patient is confused, they may not be able to comprehend their surroundings or understand potential hazards, making it critical for the nurse to ensure constant supervision or provide appropriate interventions to prevent injury. By failing to arrange for continual care, the nurse neglected to address the heightened risk of falls associated with confusion. It’s essential to either have additional staff present, use assistive devices, or involve family members to supervise the patient effectively. This proactive measure would have significantly reduced the likelihood of the patient falling when left unattended. While educating the patient about safety measures and documenting actions are important aspects of nursing care, they do not directly mitigate the immediate risk of an unattended confused patient. Similarly, restraining the patient might not be an appropriate or ethical course of action unless specifically warranted for the patient's safety, and it often comes with its own risks and ethical considerations.