The nurse is making an occupied bed. What action should the nurse implement?

A. A client with an abnormal gait who takes an anticonvulsant medication: This client is at increased fall risk due to gait instability and potential medication side effects. However, if the client can request assistance and is cognitively intact, the immediate risk is lower than for clients with impaired judgment.

B. A client with lower extremity weakness and dementia: Dementia impairs judgment, awareness of limitations, and the ability to request help, while lower extremity weakness compromises mobility. This combination places the client at highest immediate risk for unassisted falls, making activation of the bed alarm a priority.

C. A client with visual impairment who calls for assistance when needed: While visual deficits increase fall risk, the client’s ability to recognize limitations and seek help mitigates immediate danger. The fall risk is present but less urgent than for a cognitively impaired client who may attempt to get out of bed unassisted.

D. A client with hypotension who uses a walker to ambulate: Hypotension may cause dizziness, increasing fall risk during ambulation. However, if the client waits for assistance and uses mobility aids appropriately, the risk of unassisted falls is lower than in a client with dementia and mobility weakness.

A. "We should look for signs like redness, warmth, and tenderness when changing the dressing.": Monitoring for these signs of infection is appropriate and helps ensure timely intervention. Recognizing changes in wound appearance supports safe home care.

B. "Washing my hands before and after the dressing change is important to prevent infection.": Proper hand hygiene is essential for reducing the risk of introducing pathogens to the wound. This statement reflects correct understanding of infection prevention practices.

C. "I should change my dressing as prescribed, and if it becomes soiled, wet, or displaced.": Following the prescribed schedule and replacing compromised dressings helps maintain wound integrity and promotes healing. This demonstrates accurate knowledge of wound care principles.

D. "If I see any type of wound drainage, I should immediately go to the nearest hospital.": Not all drainage requires emergency care. Normal serous or slightly bloody drainage can occur during healing. Immediate hospital visits should be reserved for signs of infection, excessive bleeding, or other complications.