A nurse is caring for a client who is scheduled for a colostomy. The client tells the nurse to cancel the procedure. Which of the following responses should the nurse make?

A) Ensure the client wears nonskid slippers when walking around the house:

Wearing nonskid slippers can help improve traction and stability, reducing the risk of slips and falls, especially on smooth or slippery surfaces commonly found in homes. Ensuring the client wears nonskid slippers is a proactive measure to prevent falls.

B) Install a raised toilet seat in the client's bathroom:

A raised toilet seat can make it easier for older adults with mobility issues to sit down and stand up from the toilet safely. It reduces the distance the client needs to lower themselves, decreasing the risk of falls, especially for those with balance or strength limitations.

C) Encourage an annual review of the medications the client is taking:

Medication review is essential to identify any medications that may increase the risk of falls due to side effects such as dizziness, drowsiness, or orthostatic hypotension. An annual review ensures that any potential fall-inducing medications can be identified and addressed promptly.

D) Attach full-length side rails to the client's bed:

While side rails may prevent falls out of bed, they can also increase the risk of entrapment and injury. The use of side rails is controversial and should be based on individualized assessment and risk-benefit analysis. In many cases, alternative interventions to prevent falls should be considered before resorting to side rails.

E) Place throw rugs on uncarpeted floors in the client's home:

Throw rugs can be tripping hazards, especially for older adults with mobility issues. They can easily slip or bunch up, leading to falls. Removing throw rugs or securing them firmly to the floor is recommended to reduce the risk of falls in the home.

A) Includes quotes from the client:

Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.

B) Remains logged in to the charting system throughout the shift:

Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.

C) Makes reference in the nurse's notes of completing an incident report:

While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.

D) Documents that the provider wrote an inaccurate prescription:

Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.