A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

A) The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis: This is incorrect technique. The sterile field should always be maintained, and when opening sterile trays, the nurse should open the flap away from the body to avoid contaminating the sterile field. Opening the flap toward the body increases the risk of contamination and compromises sterility, which is critical in maintaining aseptic technique during procedures.

B) The nurse uses clean gloves when discontinuing a client's intravenous infusion: Using clean gloves when discontinuing an intravenous infusion is appropriate. Clean gloves are sufficient for this non-sterile task, as the procedure does not involve direct contact with sterile body tissues or fluids. Sterile gloves are not necessary unless the task requires maintaining sterility, such as inserting a catheter.

C) The nurse uses the client's telephone number as one form of identification when administering medications to a client: This is a correct action, as the nurse is verifying the patient's identity before administering medication. It is important to use at least two identifiers (such as the patient's name and date of birth or medical record number) to ensure accurate identification, and the patient's telephone number can be an additional form of identification.

D) The nurse empties the client's drainable colostomy pouch when it is one third full: This is an appropriate action. The nurse should empty the colostomy pouch when it is one third to one half full to prevent leakage or discomfort. This action is part of proper colostomy care and helps maintain hygiene and comfort for the patient.

A) Four wheel walker: While a four-wheel walker provides excellent support and stability for clients with significant mobility limitations, it is not always the best choice for someone who occasionally loses balance. It can be bulky and difficult to maneuver in tight spaces, and it may not provide as much support for clients who need only occasional assistance with balance. A gait belt allows for more hands-on assistance when needed.

B) Gait belt: A gait belt is the most appropriate device to use when assisting a client who occasionally loses balance. It allows the nurse to provide hands-on support and maintain the client’s safety during ambulation. The gait belt provides a secure hold, enabling the nurse to assist the client in regaining balance quickly, preventing falls if the client starts to lose their stability.

C) Jacket harness: A jacket harness is typically used in more severe cases of balance loss or in situations where the client has significant mobility impairments. While it provides more overall support, it may not be necessary for a client who only occasionally loses balance. It can also be more cumbersome than a gait belt for helping with short, occasional ambulation.

D) Cane: A cane is helpful for clients who need mild to moderate support while walking, but it might not offer enough stability for a client who occasionally loses balance. A cane may provide support in some cases, but using a gait belt would be more effective for safely supporting and guiding the client during ambulation.