A community health nurse is developing a brochure about hypertension.
Which of the following actions is the bestfor the nurse to take?

Choice A rationale:

"Determine the client's ability to use the call light." - This is the correct answer. Assessing the client's ability to use the call light is the first step in fall prevention. If the client can effectively use the call light, they can request assistance when needed, reducing the risk of falls. It's essential to assess their communication and mobility abilities.

Choice B rationale:

"Create a schedule with an assistive personnel to do hourly rounding for the client." - While hourly rounding is a valuable fall prevention strategy, assessing the client's ability to use the call light should be the initial step to ensure immediate access to help. Rounding can complement this measure.

Choice C rationale:

"Move the bedside table with the client's personal items close to the bed." - While ensuring the client's personal items are within reach is important for their comfort and convenience, it is not the first step in fall prevention. Assessing the client's ability to request assistance takes precedence.

Choice D rationale:

"Apply rubber-soled slippers before ambulation." - Providing appropriate footwear is important for fall prevention, but it is not the first precaution to implement. Assessing the client's ability to use the call light and communicate their needs comes before addressing ambulation.

Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated.

Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort.

Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.

Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.

Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.