A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

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and then

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A. Raises all four side-rails on the client's bed. Raising all four side-rails can create a risk for falls, as it may lead to a false sense of security and prevent the client from being able to exit the bed safely if needed. Additionally, it can increase the risk of entrapment or injury. The recommended practice is to keep two side-rails up while allowing for easy access and mobility for the client.
B. Locks the wheels on the client's bed. Locking the wheels on the client's bed is an appropriate action. This prevents the bed from rolling and helps ensure the client's safety, particularly when they are getting in and out of bed or during care activities.
C. Assists the client to the bathroom every 2 hr. Assisting the client to the bathroom every 2 hours is a reasonable intervention for a client at risk for falls, as it promotes regular toileting and prevents the need for urgent trips to the bathroom that could increase the risk of falling.
D. Clears furniture from the path leading to the bathroom. Clearing furniture from the path leading to the bathroom is a proactive safety measure. This reduces obstacles and hazards, promoting a safer environment for the client and minimizing the risk of falls during ambulation.

A. Diminished pulses on the affected extremity. Reduced pulses suggest impaired circulation, which may indicate compartment syndrome, a serious complication where increased pressure restricts blood flow. Without prompt intervention, this can lead to tissue damage or limb loss. The nurse should assess for additional signs such as pallor, paresthesia, and unrelieved pain and notify the provider immediately.
B. One fingerbreadth of space between the cast and the skin. This is an expected finding, as having a small space between the cast and skin allows for proper circulation and prevents excessive pressure that could lead to skin breakdown. The cast should be snug but not too tight to allow for swelling that may occur after injury or surgery. However, this does not require immediate intervention.
C. Client report of muscle spasms of the left leg. Muscle spasms are common in clients with immobilized limbs due to muscle fatigue, positioning, or nerve irritation. While uncomfortable, they do not indicate an emergency. The nurse can suggest gentle repositioning, relaxation techniques, or prescribed muscle relaxants to alleviate discomfort.
D. Ecchymosis on the inner left thigh. Bruising is a normal response to trauma and does not necessarily indicate a severe complication. It should be monitored for changes such as increasing size, pain, or signs of infection, but it does not take priority over assessing circulation and preventing limb-threatening complications.