A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first?

A. Instruct the client to report the theft to the police: While reporting to law enforcement is an option, the client may feel intimidated or unsafe doing so, and immediate protection and assessment of the situation are more urgent. The nurse’s priority is ensuring safety and initiating appropriate protective services.

B. Report the possible abuse to adult protective services: Financial exploitation is a form of elder abuse. Nurses are mandated reporters and should notify adult protective services to investigate and intervene as needed. This ensures the client’s safety, prevents further exploitation, and connects them with resources for protection and support.

C. Ask the client if there is another family member they can call for financial help: While exploring support systems is important, relying on another family member without assessment may not address potential abuse and does not fulfill the nurse’s legal obligation to report suspected exploitation.

D. Restrict visitation for the client's family until discharge: Restricting visitation may limit contact temporarily, but it does not address the underlying abuse or ensure ongoing protection. Reporting to protective services provides a structured and legal mechanism for safeguarding the client.

A. Turning off the lights in the client's room at bedtime: Keeping the room well-lit at night can help prevent disorientation and reduce the risk of falls for clients with dementia. Turning off lights may increase confusion and make wandering more dangerous, so this is not an appropriate intervention.

B. Limiting the client's physical activity during the day: Reducing daytime activity can increase restlessness and nighttime wandering. Encouraging safe physical activity during the day helps expend energy and may improve sleep patterns, making limitation counterproductive.

C. Having the client wear incontinence briefs after dinner: While incontinence briefs can prevent accidents, they do not address the underlying cause of nighttime wandering and may contribute to agitation or discomfort if used inappropriately.

D. Labeling the client's bathroom door: Clear visual cues, such as labeled doors, help clients with dementia navigate their environment independently and safely. This intervention reduces confusion, supports orientation, and can decrease wandering behaviors.