A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?

A. Elevate full-length side rails on both sides of the client's bed:

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

B. Place the bedside table 0.9 m (3 feet) away from the bed:

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

C. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

A. Check that the client has a small gauge IV catheter in place.

Blood transfusions require a large-bore IV catheter (18-20 gauge) to prevent hemolysis and ensure efficient infusion. A small gauge IV (such as 22-24G) is not appropriate for PRBCs as it can slow the infusion and damage red blood cells.

B. Check the blood product's compatibility with the client's blood type: Before administering packed red blood cells (PRBCs), the nurse must verify blood compatibility to prevent a hemolytic transfusion reaction, which can be life-threatening.

C. Prime the client's primary IV tubing with lactated Ringer’s.

Only normal saline (0.9% NaCl) should be used to prime the IV tubing for a blood transfusion. Lactated Ringer’s and dextrose solutions can cause hemolysis and clotting of the blood product.

D. Confirm the identity of the client with the blood bank technician.While verifying the blood product is critical, the nurse should confirm the client’s identity at the bedside with another licensed nurse, not the blood bank technician. This ensures that the right blood is given to the right client following facility protocols.