A nurse is reinforcing discharge teaching about postpartum activity restrictions to a client who had a cesarean birth 2 days ago. Which of the following statements by the client indicates an understanding of the teaching?

Rationale:

A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.

B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.

C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.

D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.

Rationale:

A. "I will place a night light in the hallway near the bathroom.": Installing night lights in commonly used paths, such as the hallway to the bathroom, helps prevent falls by improving visibility during nighttime trips, which is especially important for older adults with limited vision or balance.

B. "I will use a standard height toilet seat.": Standard height toilet seats can make sitting and standing more difficult for older adults. Raised toilet seats are safer and reduce the risk of falls by minimizing the effort required to use the toilet.

C. "I will set my water heater to 145 degrees Fahrenheit.": This temperature is too high and increases the risk of scald injuries. Water heaters should be set to no more than 120°F to protect older adults from accidental burns, as their skin is often thinner and more sensitive.

D. "I will cover extension cords with throw rugs.": Covering cords with rugs creates a tripping hazard. Extension cords should be secured against walls or removed altogether to reduce fall risk, especially in homes with elderly residents.