A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

Rationale:

A. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm, even with visitors present, eliminates an essential safety mechanism. The presence of visitors does not guarantee client supervision, and falls can still occur if the client attempts to get up unexpectedly.

B. Establish an elimination schedule for the client: Creating a toileting schedule helps reduce the likelihood of the client attempting to ambulate independently to the bathroom, which is a common time for falls. This proactive approach promotes safety and preserves dignity.

C. Allow the client to walk unassisted near the nursing station: Even when close to staff, allowing a fall-risk client to walk unassisted increases the chance of injury. Supervision does not replace physical support or assistive devices for those at risk.

D. Raise all four bed rails on the client's bed: Raising all four bed rails is considered a form of restraint and may increase injury risk if the client attempts to climb over them. Instead, using two rails and other fall precautions is safer and more appropriate.

Rationale:

A. Place the oxygen tank away from curtains or drapes: Oxygen supports combustion, so tanks must be kept away from flammable materials such as curtains or drapes. This placement reduces fire risk and ensures safe home oxygen use.

B. Store the oxygen tank wrench in a locked cabinet: The tank wrench should remain attached to or easily accessible near the tank for emergency shut-off. Locking it away could delay quick responses during equipment malfunction or fire hazards.

C. Ensure that the client checks the gauge weekly: Oxygen tank levels should be checked daily to prevent running out unexpectedly. Waiting a week between checks increases the risk of the tank depleting before a refill is arranged.

D. Have the client store smaller tanks under his bed: Storing tanks under the bed poses a fire hazard due to limited ventilation and proximity to bedding. Oxygen tanks should be stored upright in a secure, well-ventilated area away from heat sources.