A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

A. Administer medication for high blood pressure: This is a dependent intervention as it requires a healthcare provider's order and is part of prescribed treatment.
B. Reposition the client every 2 hours: This is an independent nursing intervention, as it involves routine care that nurses can perform without needing a specific provider's order.
C. Starting IV antibiotics: This is a dependent intervention that requires a healthcare provider’s order and typically involves more specialized procedures.
D. Administering medication for pain: This is also a dependent intervention because it requires a healthcare provider's prescription and direction for administration.

A. Remove the dentures from the body: Dentures should typically be left in place unless otherwise directed, as removing them can alter the appearance of the deceased and may be distressing for the family.
B. Dim the lights in the room: Dimming the lights can create a more respectful and soothing environment for the family during their time of mourning.
C. Remove all equipment from the bedside: Removing equipment ensures a clear and respectful presentation of the body, allowing the family to view their loved one without distractions.
D. Apply fresh linens and place a clean gown on the body: This action helps present the body in a respectful manner, making it more presentable for the family.
E. Make sure the body is lying completely flat: The body should be positioned appropriately based on the clinical setting and family preferences, but the focus should be on creating a respectful and dignified presentation rather than strictly ensuring the body is completely flat.