A nurse is caring for a patient diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement

A) Assess the client every 4 hr: Assessing the client every 4 hours is not frequent enough, especially for patients at high risk for falls. A more frequent assessment, such as every 1-2 hours or as clinically appropriate, is recommended to monitor the patient's safety and to ensure timely intervention if needed.

B) Keep the client's room dark at night: Keeping the room dark at night would increase the risk of falls. Adequate lighting should be provided to ensure the client can safely navigate the room and call for assistance if necessary. Nightlights or low-level lighting are often used to prevent accidents in the dark.

C) Teach the client to use the call light: This is an essential action to prevent falls. Teaching the client to use the call light ensures that they can summon help if they need assistance to get out of bed or move around, reducing the risk of attempting to move independently and falling.

D) Keep the client's bed in the lowest position: This is a key safety measure. Keeping the bed in the lowest position reduces the risk of injury if the client attempts to get out of bed independently or if they fall. It also makes it easier for the client to safely exit the bed with assistance.

E) Place a fall-risk identification band on the client's wrist: This is an important action to alert all healthcare staff about the client's fall risk. A fall-risk identification band helps ensure that everyone involved in the patient's care is aware of the need for extra precautions to prevent falls.

A) Slide the patient into the new position: Sliding a patient when repositioning can create shear forces on the skin, which may contribute to skin damage. Shearing can occur when the skin sticks to the surface while the underlying tissues move, leading to increased risk of pressure ulcers. Therefore, sliding is not considered the most effective or safest way to reposition a patient at risk for skin impairment.

B) Place the patient in a 30-degree supine position: Placing the patient in a 30-degree supine position is a good method for reducing pressure on bony prominences and minimizing the risk of pressure injuries. However, while this position is helpful for preventing skin breakdown, it does not address the method of repositioning, which is what is being asked in this question.
C) Utilize a transfer device to lift the patient: Using a transfer device, such as a lift or slide sheet, to lift the patient is the best method for repositioning. This technique helps to reduce friction and shear forces on the skin, providing a safer and more effective way to move the patient without causing damage. Transfer devices also allow for a smoother repositioning, minimizing the risk of skin impairment.

D) Elevate the head of the bed 45 degrees: Elevating the head of the bed to 45 degrees can increase the risk of pressure injuries, especially if the patient is immobile and cannot relieve pressure themselves. This position can also contribute to shear forces as the patient slides downward. It may be appropriate in certain clinical situations, but it does not directly address the method of repositioning.