128. A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right. placing them in the selected order of performance, use all the steps.) (ORDERED RESPONSE)

A. Allow the client to walk unassisted near the nursing station: Even in a monitored area, allowing an at-risk client to ambulate unassisted increases the chance of falling. Clients on fall precautions should always have supervision or assistive devices during ambulation.
B. Establish an elimination schedule for the client: Scheduled toileting reduces the risk of unassisted attempts to get out of bed, a common cause of falls in hospitalized clients. It supports safety by addressing one of the most frequent fall triggers.
C. Raise the four bed rails on the client’s bed: Using all four bed rails can be considered a form of restraint and may increase fall risk if the client tries to climb over them. Two or three side rails are safer and still provide support.
D. Silence the bed alarm when visitors are at the client’s bedside: Bed alarms are a key fall prevention tool. Silencing them reduces their effectiveness and can delay the response to unsupervised movement, even if visitors are present.

A. “Avoid high-fiber foods while taking this medication.”: Fentanyl can cause constipation, so a diet high in fiber is actually recommended to promote bowel regularity. Avoiding fiber would worsen one of the drug’s common side effects.
B. “Remove the patch for 8 hours every day to reduce the risk of tolerance.": Fentanyl patches are designed for continuous, 72-hour use. Removing the patch disrupts pain control and may lead to withdrawal symptoms or inadequate analgesia.
C. “Avoid hot tubs while wearing the patch.”: Heat exposure, including hot tubs or heating pads, can increase fentanyl absorption, potentially leading to overdose. Clients should be advised to avoid external heat sources near the patch.
D. “Apply the patch to your forearm.”: The patch should be applied to a flat, non-irritated area of the upper torso or upper arm. The forearm is not typically recommended due to its mobility and potential for detachment or reduced absorption.