A nurse is caring for a client in active labor.

The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

A. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm compromises safety by preventing timely notification if the client attempts to get out of bed unassisted. Bed alarms should remain active at all times for clients on fall precautions.

B. Establish an elimination schedule for the client: Scheduling regular toileting reduces the risk of falls by minimizing unassisted trips to the bathroom, which are a common cause of falls, especially in clients with mobility or cognitive impairments. This is an effective and preventive intervention.

C. Allow the client to walk unassisted near the nursing station: Clients on fall precautions should not ambulate without assistance or appropriate safety measures, even near the nursing station, as unassisted walking increases the risk of falls.

D. Raise all four bed rails on the client's bed: Raising all four bed rails can increase the risk of injury if the client attempts to climb over them and is generally considered a restraint, which requires careful assessment and provider authorization.

A. Offer the client saltine crackers between meals: Dry foods like saltine crackers can worsen the discomfort associated with xerostomia and may irritate oral mucosa. They are not recommended for managing dry mouth.

B. Instruct the client on the use of esophageal speech: Esophageal speech is a technique used after laryngectomy, not for managing xerostomia. It does not address the underlying issue of dry mouth caused by radiation therapy.

C. Provide humidification of the room air: Humidifying the room adds moisture to the environment, helping relieve dryness in the oral cavity and throat. This intervention is appropriate for managing xerostomia and improving comfort for clients post-radiation therapy.

D. Suggest rinsing his mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can further dry and irritate the oral mucosa, worsening xerostomia. Clients should be advised to use non-alcoholic, moisturizing rinses instead.