A nurse is reinforcing teaching with another nurse about how change an ostomy appliance for a client who has sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A) Assists the client to the bathroom every 2 hr: This action is appropriate as regular assistance with toileting can help prevent falls by ensuring the client is not trying to get up unassisted when they need to use the bathroom. Assisting every 2 hours is reasonable to minimize the risk of falls, especially in clients who are at risk.

B) Clears furniture from the path leading to the bathroom: This action is correct as it reduces environmental hazards that could contribute to a fall. Ensuring that the path to the bathroom is free from obstacles is a key safety measure for clients at risk for falls.

C) Raises all four side-rails on the client's bed: This is an action the nurse should intervene on. Raising all four side rails is considered a restraint in many settings and could increase the risk of injury if the client tries to climb over or becomes entangled. It can also contribute to a feeling of entrapment or confusion. Side rails should only be used according to specific protocols and when necessary for safety, not as a blanket solution for fall prevention.

D) Locks the wheels on the client's bed: Locking the wheels on the bed is an appropriate safety measure. Ensuring the bed is stationary when the client is in it reduces the risk of accidental movement and potential falls.

A. Respiratory complaint: A 4-day productive cough with fatigue and night sweats raises concern for a respiratory infection, including tuberculosis (TB) or pneumonia. Further evaluation, including chest imaging and sputum studies, is warranted.
B. Temperature: A low-grade fever (38.1°C/100.5°F) for several days, along with night sweats, suggests a possible infectious process, requiring further investigation.
C. Sputum characteristics: Blood-tinged sputum raises concern for TB, bronchitis, pneumonia, or malignancy, necessitating a sputum culture and acid-fast bacillus (AFB) testing.
D. Weight: Unintentional weight loss (5 lb in 1 week) and decreased appetite can indicate chronic infection, malignancy, or another systemic illness, necessitating further evaluation.
G. Travel history: Recent travel to South Africa, a country with a high TB prevalence, increases the risk of tuberculosis exposure and justifies further screening.
Incorrect Choices:
E. Blood pressure: 112/88 mm Hg is within the normal range and does not require further evaluation.
F. Oxygen saturation: 98% on room air is normal and does not indicate respiratory compromise.
H. Heart rate: 98/min is slightly elevated but could be due to fever or mild dehydration. It is not a primary concern.