A nurse is providing discharge instructions to a client about proper use of a cane for maximum support. Which of the following statements by the client indicates an understanding of the teaching?

A. "Remove clocks from the client's room." –
Removing clocks can increase confusion and disorientation. Instead, having a visible clock and calendar can help the client stay oriented.
B. "Check on the client frequently while he is in the restroom." –
While frequent monitoring is important, excessive surveillance may increase agitation and distress. A better alternative is to ensure the restroom is safe and accessible.
C. "Encourage physical activity throughout the day to expend energy." –
Engaging the client in physical activity helps reduce restlessness, promotes better sleep, and decreases the likelihood of agitation, which can reduce the need for restraints.
D. "Use full-length side rails on the client's bed." –
Full-length side rails can be considered a form of restraint as they may limit movement and increase the risk of falls or injury if the client tries to climb over them.

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

1. 1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
   2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
   3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

1. 1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
   2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
   3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

1. Client 3 – Pulmonary Edema (Airway/Breathing concern)
   2. Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
   3. Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
   4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
   5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
   6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)