A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take.

Choice A rationale

A color-coded wristband, such as yellow, serves as a visual cue to all healthcare staff that a client has an increased risk of falling. This system promotes a universal understanding of the client's needs, allowing all members of the care team to implement appropriate fall prevention measures proactively and consistently, such as providing assistance with ambulation or frequent rounding.

Choice B rationale

The use of physical restraints, such as a restraint around the waist, is a last resort and requires a provider's order. It is not considered a primary fall prevention strategy. Restraints can increase a client's risk of injury and are associated with negative outcomes, including agitation, skin breakdown, and loss of muscle mass. Fall prevention strategies focus on proactive, non-restrictive interventions.

Choice C rationale

Storing personal items in a bathroom, especially on a high shelf, creates a significant fall hazard. The client may overreach or stand on a stool to retrieve items, increasing their risk of losing balance. To prevent falls, all personal items should be kept within easy reach of the client, such as on the bedside table, to minimize unnecessary movement.

Choice D rationale

While keeping some light on is helpful, having overhead lights on at all times can cause glare and create shadows that distort depth perception. This can make it difficult for a client with vision impairments to see potential obstacles. A low-level nightlight is a safer alternative for nighttime visibility, as it minimizes glare and helps maintain a normal sleep-wake cycle. *.

Choice A rationale

Measuring the client's legs with a tape measure is the correct action to ensure proper sizing of the antiembolic stockings. Correct sizing is critical for effective venous compression and to prevent complications such as skin irritation, tissue damage, or impaired circulation. Stockings that are too tight can act as a tourniquet, while those that are too loose will not provide the necessary graduated compression to facilitate venous return and prevent blood stasis, which is the underlying cause of deep-vein thrombosis. This precise measurement ensures the stockings fit snugly and provide optimal therapeutic benefit.

Choice B rationale

Removing the stockings every 24 hours is an insufficient interval for skin integrity checks and to allow for proper cleaning and assessment. The standard practice involves removing antiembolic stockings at least twice daily for a short period. This allows the nurse to inspect the client's skin for any signs of pressure, irritation, or breakdown, and to perform hygiene. Prolonged, continuous wear without breaks can compromise skin integrity and increase the risk of developing pressure injuries, especially in a client who is less mobile due to their condition.

Choice C rationale

Folding the stockings at the top is a harmful and dangerous practice. Folding creates a constrictive band around the client's leg, which acts as a tourniquet. This constriction impedes venous and lymphatic return, leading to increased risk of blood stasis, edema, and tissue damage. The pressure from the folded band can severely compromise circulation and potentially worsen the client's underlying deep-vein thrombosis. The stockings should be smooth and wrinkle-free to provide uniform graduated compression.

Choice D rationale

Massaging the legs of a client with deep-vein thrombosis (DVT) is contraindicated and can be extremely dangerous. Massaging can dislodge the thrombus (blood clot) from the venous wall. If the clot becomes dislodged, it can travel through the bloodstream, leading to a pulmonary embolism (PE), a life-threatening condition where the clot obstructs a pulmonary artery in the lungs. Therefore, any form of massage or direct pressure on the affected limb is strictly avoided to prevent this potentially fatal complication. *.