The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning, what should the nurse anticipate?

A) Assess the client every 4 hr: Assessing the client every 4 hours is not frequent enough, especially for patients at high risk for falls. A more frequent assessment, such as every 1-2 hours or as clinically appropriate, is recommended to monitor the patient's safety and to ensure timely intervention if needed.

B) Keep the client's room dark at night: Keeping the room dark at night would increase the risk of falls. Adequate lighting should be provided to ensure the client can safely navigate the room and call for assistance if necessary. Nightlights or low-level lighting are often used to prevent accidents in the dark.

C) Teach the client to use the call light: This is an essential action to prevent falls. Teaching the client to use the call light ensures that they can summon help if they need assistance to get out of bed or move around, reducing the risk of attempting to move independently and falling.

D) Keep the client's bed in the lowest position: This is a key safety measure. Keeping the bed in the lowest position reduces the risk of injury if the client attempts to get out of bed independently or if they fall. It also makes it easier for the client to safely exit the bed with assistance.

E) Place a fall-risk identification band on the client's wrist: This is an important action to alert all healthcare staff about the client's fall risk. A fall-risk identification band helps ensure that everyone involved in the patient's care is aware of the need for extra precautions to prevent falls.

A) Complete an incident report: While it is essential to complete an incident report, this is not the first action to take. Completing the report documents the event but should come after immediate steps are taken to prevent further complications and ensure the nurse's safety. The priority is to first address the injury and ensure the site is properly cleaned.

B) Request the risk manager obtain consent for HIV testing from the client: Requesting consent for HIV testing from the client is important, but it is not the first priority. The immediate action should focus on treating the injury and reducing the risk of infection. Once the injury is addressed, the next step is to assess the potential for exposure and initiate testing or other preventive measures.
C) Consent to postexposure treatment with antiretroviral medications: Postexposure prophylaxis (PEP) with antiretroviral medications is an important step after a needle-stick injury, especially if the source patient has an unknown HIV status or is known to be HIV-positive. However, this step should come after immediate wound care and before initiating any further testing or preventive treatments.

D) Wash the site of injury with soap and water: The first and most crucial step after a needle-stick injury is to immediately wash the wound thoroughly with soap and water. This action helps reduce the risk of infection by removing any potential contaminants from the needle or the environment. After cleaning the wound, the nurse should then proceed with further steps, such as reporting the incident, obtaining consent for HIV testing, and considering PEP if indicated.