A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

A. Notifying the facility operator is important, but it is not the immediate priority when there is a fire endangering the client's safety.

B. While closing fire doors can help contain the fire, it is not the priority action after ensuring the client's immediate safety.

C. Turning off oxygen sources is crucial because oxygen can fuel the fire and cause it to spread rapidly. This action helps prevent the fire from worsening.

D. Putting out the fire with the appropriate extinguisher is important, but it comes after ensuring the fire's fuel source is cut off to prevent further escalation of the fire.

A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.

B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.

C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.

D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.