A night shift nurse works and cares for several clients at risk for falls.
Which of the following actions should the nurse take?

Choice A rationale:

Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.

Choice B rationale:

Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.

Choice C rationale:

Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.

Choice D rationale:

Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.

The correct answer is Choice C.

Choice A rationale: Using a fire extinguisher is part of containment, but it follows evacuation. Attempting to extinguish before removing clients violates RACE protocol and risks patient injury from smoke or electrical fire.

Choice B rationale: Activating the fire alarm initiates emergency response but comes after client rescue. Per RACE (Rescue, Alarm, Contain, Extinguish), client safety is prioritized before system-wide alerts.

Choice C rationale: Moving clients to safety is the first step in fire response. It aligns with the “Rescue” phase of RACE, ensuring immediate protection from smoke inhalation, electrical hazards, and fire spread.

Choice D rationale: Confine by closing doors and windows is part of containment, which follows rescue and alarm activation. It helps limit fire spread but is not the initial priority in patient-centered emergencies.