A nurse is teaching a client who reports insomnia. Which of the following statements should the nurse make?

Choice A reason: Applying socks without non-slip soles during ambulation increases fall risk due to reduced traction on smooth surfaces. Non-slip footwear or hospital-grade socks with grips are preferred to ensure stability. Socks alone do not provide sufficient grip, potentially leading to slips, especially in elderly or mobility-impaired clients, making this an unsafe fall prevention strategy.

Choice B reason: Locking the wheels on a client’s bed prevents unintended movement during transfers or repositioning, reducing fall risk. Stable beds ensure a secure base for clients with impaired mobility or balance, minimizing accidents. This is a standard safety measure in healthcare settings to enhance client safety during bed-related activities, such as getting in or out of bed.

Choice C reason: Placing brakes on wheelchairs ensures stability during transfers, preventing the chair from moving unexpectedly. This is critical for clients with limited mobility or strength, as an unlocked wheelchair can shift, leading to falls. Applying brakes is a fundamental safety practice in fall prevention protocols, ensuring a secure environment for safe client transfers.

Choice D reason: Keeping the bed in a high position increases fall risk, as it elevates the distance to the floor, making falls more dangerous, especially for confused or mobility-impaired clients. Beds should be kept in the lowest position when unattended to minimize injury risk, making this an incorrect strategy for fall prevention in healthcare settings.

Choice E reason: Providing under-bed lighting at night improves visibility, reducing fall risk by helping clients see obstacles or orient themselves in low-light conditions. Adequate lighting mitigates disorientation, particularly for elderly clients or those with visual impairments, supporting safe ambulation and transfers, making it an effective component of fall prevention strategies.

Choice A reason: Using one cotton swab to clean the urinary meatus is insufficient for proper antisepsis during catheter insertion. Multiple swabs (typically 3-5) with antiseptic solution are required to thoroughly clean the meatus, reducing the risk of urinary tract infections by ensuring adequate disinfection of the periurethral area.

Choice B reason: Applying an oil-based lubricant is incorrect, as it can cause catheter material degradation and increase infection risk if aspirated. Water-based lubricants are standard, as they are safe for mucosal surfaces, reduce friction, and minimize trauma during insertion, ensuring patient safety and catheter integrity.

Choice C reason: Donning sterile gloves is essential for indwelling urinary catheter insertion to maintain a sterile field and prevent urinary tract infections. The urethra is a sterile environment, and sterile technique minimizes pathogen introduction, ensuring patient safety and reducing complications like catheter-associated urinary tract infections, making this the correct action.

Choice D reason: Testing the balloon before insertion is standard but is not the primary action listed, as it precedes sterile glove application. While important to ensure catheter functionality, it is a preparatory step. Sterile gloves are critical during the insertion process to maintain asepsis, making this less immediately relevant.