A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?

Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.

Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.

Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.

Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.

Choice A reason: Filling the pad with sterile water is not necessary, as tap water can be used for an aquathermia pad without increasing the risk of infection or contamination.

Choice B reason: Using safety pins to secure the pad in place is not appropriate, as they can puncture or damage the pad and cause leakage or electric shock.

Choice C reason: Applying the pad for 45 min at a time is not recommended, as it can cause skin burns or tissue damage due to prolonged exposure to heat. The nurse should apply the pad for no more than 20 min at a time and check the skin frequently for signs of redness or blistering.

Choice D reason: Covering the pad prior to use is an important action, as it can prevent direct contact between the pad and the skin and reduce the risk of burns or irritation. The nurse should use a towel or a cloth to cover the pad before applying it to the affected area.