The nurse has received the shift report. Which client should the nurse assess first?

Fall prevention strategies focus on mitigating environmental hazards and optimizing patient mobility to prevent musculoskeletal or head injuries. Effective nursing goals prioritize the maintenance of physical integrity and the achievement of specific, functional milestones during the hospital stay. By utilizing measurable outcomes, the nurse can objectively evaluate the success of safety interventions and adjust the plan of care to ensure continuous protection.

Rationale:

A. This statement describes a nursing intervention rather than a client-centered goal. An appropriately worded goal must focus on the behavior or status of the client, such as "The client will demonstrate the use of the call light." Goals should reflect what the patient will achieve, not the actions the nurse will perform during the shift.

B. Restraint use is a reactive safety measure and an intervention of last resort, not a positive client goal. Promoting a restraint-free environment is a standard of care, and goals should focus on maintaining safety through less restrictive means. A goal should describe a desired health state rather than the application of a restrictive mechanical device.

C. Remaining free from injury is the ultimate outcome for a patient at risk for falls. This goal is specific to the safety concern and provides a clear metric for evaluating the effectiveness of the fall prevention protocol. It addresses the prevention of fractures, lacerations, or other forms of physical harm during the nursing care period.

D. This goal is appropriately worded because it is measurable and contains a specific time frame (while hospitalized). It focuses on a functional task—walking from a bed to a chair—which allows the nurse to observe and document the client's ability to move without falling. Clear parameters allow for consistent evaluation by the multidisciplinary healthcare team.

E. Bed rest is an intervention that can lead to deconditioning and an increased risk of falls upon eventual mobilization. A goal should focus on rehabilitation or safety during necessary movement rather than the restriction of all activity. Prescribing bed rest is a provider-led intervention and does not constitute a SMART client-centered goal for mobility.

Fire suppression involves interrupting the chemical chain reaction by removing heat, fuel, or oxygen. Class B fires involve flammable liquids like petroleum or gases, requiring agents that smother or inhibit vapor production to prevent thermal decomposition.

Rationale:

A. Oil is a non-polar liquid categorized under Class B hazards. Fire extinguishers for this class utilize aqueous film-forming foam or dry chemicals to create a barrier that interrupts oxygen supply, effectively cooling the fuel surface to stop combustion.

B. Alcohols are polar solvents that burn at high temperatures. Suppression requires specialized alcohol-resistant agents to prevent the foam blanket from dissolving. Class B units are specifically engineered to handle such volatile liquid fires through vapor suppression.

C. Electrical equipment fires are categorized as Class C. Using a Class B extinguisher containing conductive agents could cause electrical shock to the operator. Class C fires require non-conductive extinguishing media like carbon dioxide to safely neutralize the hazard.

D. Plastic is a solid combustible material classified under Class A. These fires typically require the cooling effect of water or multipurpose dry chemicals. Class B extinguishers are not the primary choice for ordinary combustibles like synthetic polymers.

E. Wood is a fibrous material belonging to the Class A category. Effective extinguishment requires deep heat reduction often provided by pressurized water. A standard Class B unit lacks the penetrating power necessary to extinguish deep-seated embers in cellulose-based materials.