A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply,

A) Clean the skin near the drain in a circular motion from the outside to the inside:
When cleaning around a drain, the nurse should use a circular motion, but it is important to clean from the inside (near the drain) outward to prevent introducing bacteria into the drain site. Cleaning from the outside to the inside increases the risk of contaminating the wound and could cause infection.

B) Empty the drainage device when it is half full:
For a Penrose drain, the drainage is typically absorbed by a dressing rather than being collected in a drainage device. In general, for drains like Jackson-Pratt or Hemovac, emptying the device when it is half full is correct, but this is not applicable to a Penrose drain. A Penrose drain relies on passive drainage, and there is no reservoir that requires emptying.

C) Place a perforated gauze pad around the drain to absorb drainage:
A Penrose drain is an open drain that allows drainage of fluids from a wound or surgical site. A perforated gauze pad should be placed around the drain to absorb the drainage and keep the surrounding area clean and dry. This helps prevent infection and maintains a sterile environment around the wound.

D) Connect the drain to continuous low-pressure suction:
A Penrose drain does not require suction. It is a passive drain, relying on gravity to facilitate the drainage of fluid. Suction is typically used for other types of drains, such as Jackson-Pratt or Hemovac drains, which require a suction mechanism to actively draw out fluid.

A. Electrical cord on floor over a walkway:
An electrical cord on the floor in a walkway poses a significant tripping hazard. Clients may not notice the cord or may have difficulty stepping over it, increasing the risk of falls, particularly for individuals with impaired mobility or vision.

B. Demonstrates correct use of cane to ambulate:
Proper use of a cane improves balance and stability, reducing fall risk rather than contributing to it. Clients who demonstrate correct usage are actively minimizing their likelihood of falling.

C. Grab bar in the bathroom:
Grab bars provide added support and stability, particularly in areas prone to slips, such as bathrooms. Their presence is a preventive measure rather than a fall risk.

D. Diagnosis of Macular degeneration:
Macular degeneration impairs central vision, which can lead to difficulties in detecting obstacles and maintaining balance, increasing the client’s susceptibility to falls.

E. Throw rugs in kitchen:
Throw rugs are a well-documented fall hazard because they can slip, bunch up, or create uneven surfaces. They are particularly risky for older adults and those with mobility impairments.