A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?

Choice A: WBC Count

Reason: The white blood cell (WBC) count is not directly related to fall risk. WBC count is an indicator of the immune system’s response to infection or inflammation. In this case, the patient’s WBC count is within the normal range (5,000 to 10,000/mm³) on both days. Therefore, it does not contribute to an increased risk of falls.

Choice B: Parkinson’s disease

Reason: Parkinson’s disease significantly increases the risk of falls due to several factors. Patients with Parkinson’s often experience postural instability, which is the inability to maintain balance when standing or walking. This condition is a cardinal feature of Parkinson’s disease and can lead to frequent falls. Additionally, Parkinson’s patients may experience freezing of gait, where they suddenly cannot move their feet forward despite the intention to walk. This can cause them to fall. Other gait abnormalities, such as festinating gait (short, rapid steps) and dyskinesias (involuntary movements), also contribute to the increased fall risk.

Choice C: Potassium level on day 2

Reason: The patient’s potassium level on day 2 is 3.0 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. Low potassium levels (hypokalemia) can lead to muscle weakness, cramps, and fatigue. These symptoms can impair the patient’s ability to maintain balance and increase the risk of falls. Hypokalemia can also cause abnormal heart rhythms, which can further contribute to the risk of falls.

Choice D: Furosemide

Reason: Furosemide is a diuretic medication used to treat conditions such as heart failure by reducing fluid buildup in the body. However, it can also cause orthostatic hypotension, a condition where blood pressure drops significantly when standing up. This can lead to dizziness, lightheadedness, and an increased risk of falls. Additionally, furosemide can cause electrolyte imbalances, such as low potassium levels, which can further contribute to fall risk.

Choice E: Low blood pressure

Reason: The patient’s blood pressure readings indicate orthostatic hypotension, with a significant drop from 128/56 mm Hg while sitting to 92/40 mm Hg while standing. Orthostatic hypotension is a common condition in patients with Parkinson’s disease and heart failure. It can cause dizziness, lightheadedness, and fainting when changing positions, increasing the risk of falls. The patient’s low blood pressure when standing is a clear indicator of increased fall risk.

Choice A reason:

Draw sheet: A draw sheet can be used to assist in repositioning a patient, but it is not the most effective method for turning a client who has undergone spinal fusion. The primary concern is to maintain spinal alignment, which is best achieved through the log roll technique.

Choice B reason:

Log roll: The log roll technique is the preferred method for turning patients who have had spinal surgery. This technique involves moving the patient as a single unit, keeping the spine in alignment to prevent any twisting or bending that could disrupt the surgical site. It is especially important for obese patients to ensure that the spine remains stable during movement.

Choice C reason:

Sliding board: A sliding board is typically used to assist with transfers from one surface to another, such as from a bed to a wheelchair. It is not suitable for turning a patient in bed, particularly one who has had spinal surgery.

Choice D reason:

Hoyer lift: A Hoyer lift is a mechanical device used to lift and transfer patients who are unable to move themselves. While it can be useful for transferring patients, it is not designed for turning patients in bed and does not provide the necessary support to maintain spinal alignment during a turn.