The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

Choice A reason: The rebound phenomenon, related to cerebellar function, is irrelevant to heating pad application. Heat therapy requires assessing skin sensation to prevent burns. Neurosensory impairment increases burn risk, making sensory assessment critical. Checking for rebound phenomenon does not address the immediate safety concerns of heat application.

Choice B reason: Muscle strength and tone inform mobility or rehabilitation but are not primary concerns for heating pad use. Impaired sensation heightens burn risk, as clients may not feel excessive heat. Sensory assessment takes precedence to ensure safe application, as muscle status does not directly impact heat therapy safety.

Choice C reason: Limitations to range of motion are relevant for mobility but not critical for heating pad safety. Neurosensory impairment increases the risk of burns, as clients may not detect overheating. Sensory assessment ensures the client can report discomfort, making it the priority over joint mobility before applying heat.

Choice D reason: Assessing neurosensory impairment is critical before applying a heating pad, as impaired sensation increases burn risk. Clients with neuropathy or reduced sensation may not feel excessive heat, leading to tissue damage. This assessment ensures safe application, aligning with nursing safety protocols to prevent thermal injury during heat therapy.

Choice A reason: Encouraging relaxation through massage may reduce agitation but does not directly prevent falls. Confusion increases fall risk, requiring environmental safety measures. Massage lacks evidence as a primary fall prevention strategy, making it less effective than alarms or bed adjustments for a confused, high-risk client.

Choice B reason: Lowering the bed height reduces fall injury risk but is less proactive than a pressure-sensitive alarm. Alarms alert staff to movement, preventing falls before they occur. Bed height adjustment is a secondary measure, as it mitigates injury rather than addressing the immediate risk of unsupervised movement.

Choice C reason: Setting up a pressure-sensitive alarm on the bed and chair alerts staff when the confused client attempts to move, preventing falls. This proactive measure addresses the high fall risk in real-time, aligning with evidence-based safety protocols. Alarms are critical for confused clients, ensuring timely intervention to maintain safety.

Choice D reason: Placing the client in a safety vest is a restraint, which is a last resort due to ethical and safety concerns. Restraints can increase agitation and injury risk in confused clients. Pressure-sensitive alarms are less invasive, promoting safety without compromising autonomy, making them the preferred fall prevention strategy.