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) Thrombus formation:
While immobility increases the risk of thrombus formation due to stasis of blood in the veins, hypercalcemia is not directly linked to thrombus formation. However, immobility and hypercalcemia could contribute to increased clotting risk indirectly, but renal stones are a more direct concern in this situation.

B) Pressure ulcers:
Pressure ulcers are a common concern for immobilized patients due to prolonged pressure on bony prominences. However, hypercalcemia does not directly cause or increase the risk of pressure ulcers. While immobility is a risk factor for pressure ulcers, hypercalcemia is not the primary cause for concern in this case.

C) Renal stones:
Hypercalcemia (elevated calcium levels in the blood) can lead to the formation of renal stones (kidney stones), as excess calcium is often excreted in the urine, where it can crystallize and form stones. This is the most direct and significant concern for a patient with high calcium levels. Monitoring for renal stones would be the priority action for the nurse in this case.

D) Hypostatic pneumonia:
Hypostatic pneumonia occurs due to immobility, causing mucus accumulation in the lungs and subsequent infection. While immobility is a concern for pneumonia, it is not specifically linked to hypercalcemia. The nurse should be monitoring for pneumonia in any immobilized patient, but the more immediate risk related to hypercalcemia is renal stones.

A) Place the bedside table within the client's reach: This is an important safety measure to help prevent falls. By ensuring that the bedside table is within easy reach, the client will be less likely to try to reach for objects outside their immediate area, reducing the risk of falls from overextending or getting up unnecessarily.

B) Teach balance and strengthening exercises: Teaching balance and strengthening exercises is a key preventative measure for older adults at risk for falls. These exercises help improve muscle strength, coordination, and stability, which can significantly reduce the likelihood of falls.

C) Provide information about home safety checks: Providing information about home safety is essential to prevent falls in older adults. This includes advising the patient on eliminating hazards (like loose rugs, clutter, or inadequate lighting) and ensuring that the home environment is conducive to safety. A home safety check is part of creating a fall-prevention strategy.

D) Administer sedative at bedtime: Administering sedatives to older adults, especially those at risk for falls, can increase the likelihood of confusion, dizziness, or impaired coordination, which can lead to falls. This is not a recommended intervention. Non-pharmacologic methods for improving sleep hygiene should be prioritized over sedative medications when possible.

E) Lock beds and wheelchairs when not providing care: Locking beds and wheelchairs when not in use is a fundamental safety measure to prevent accidental movement of the bed or wheelchair. This action reduces the risk of the patient falling out of bed or from a wheelchair if they try to move or shift positions.