A charge nurse is teaching a newly licensed nurse about the guidelines for legal scope of practice. For reference, which of the following sources should the nurse consult?

A. "Report a firm ridge below the breasts to the provider." A firm ridge along the bottom curve of the breast can be normal. It’s important to distinguish between normal breast tissue and abnormal lumps. Encouraging clients to report any changes or new lumps to the provider is more appropriate.
B. "Keep your arm relaxed at your side on the side you are examining." The correct technique involves raising the arm on the side being examined to help spread out the breast tissue, making it easier to palpate for lumps and abnormalities.
C. "Use your thumb and forefinger to palpate each breast for lumps." The correct technique involves using the pads of the fingers (not the thumb and forefinger) to palpate the breast in a systematic pattern, such as circular motions or vertical strips, to thoroughly check all areas of the breast.
D. "Use firm pressure to palpate near the area of the ribs and chest wall." Using firm pressure is appropriate for palpating deeper tissues closer to the ribs and chest wall, as this helps detect lumps that may not be superficial.

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.