A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

D. Capillary refill time greater than 2 seconds suggests impaired peripheral circulation, which could indicate vascular compromise or inadequate perfusion to the extremity. In a client with an external fixator, compromised circulation could lead to serious complications such as compartment syndrome or tissue necrosis.
A. This finding may be within the expected range for drainage following surgery, particularly if the client has undergone orthopedic surgery involving the placement of an external fixator. However, the nurse should continue to monitor the drainage and assess for any signs of increased bleeding or hematoma formation.
B. While a low-grade fever alone may not require immediate intervention, the nurse should assess the client further for other signs and symptoms of infection, such as increased pain, redness, warmth, or drainage at the surgical site.
C. While the client's pain level of 7 may require intervention to manage discomfort, it does not necessarily indicate an immediate threat to the client's safety or well-being.

D. Limiting the time that visitors spend with the client is a reasonable precaution to reduce their overall radiation exposure. Prolonged exposure to radiation can increase the risk of adverse effects. By limiting visitors to a specific time frame, the nurse can help control their exposure while still allowing for social support and companionship.
A. Discarding radioactive materials in regular trash cans can pose significant risks to sanitation workers, the environment, and public health.
B. Proper disposal of soiled linens contaminated with radioactive materials is essential to prevent radiation exposure to others. Soiled linens should be handled and disposed of according to institutional protocols for managing radioactive waste.
C. Maintaining a safe distance from the client is an important radiation safety precaution. However, this alone may not be sufficient to ensure adequate protection, depending on the specific circumstances of the treatment and the level of radiation emitted by the sources.