A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Apply petroleum jelly around and inside the nares:

Petroleum jelly is not recommended for use with oxygen therapy. It can be flammable and may increase the risk of fire when in contact with oxygen.

B. Cleanse the mask or collar with soapy water every other day:

While it's important to keep the oxygen equipment clean, using soapy water might not be suitable for all types of oxygen masks or collars. Specific cleaning instructions provided by the supplier or healthcare provider should be followed to ensure proper hygiene and maintenance of the equipment.

C. Make sure the straps on the mask are secure but not too tight:

Proper fitting of the oxygen mask is crucial for comfort and adequate oxygen delivery. The straps should be secure enough to hold the mask in place but not so tight as to cause discomfort or skin irritation.

D. Post "no smoking" warning signs at home in a prominent location:

Oxygen is highly combustible, and smoking near oxygen can lead to fires or explosions. It's crucial to have clear warning signs in the home to prevent smoking in areas where oxygen is used.

E. Check the tops of his ears regularly for skin breakdown:

Prolonged use of oxygen masks or nasal cannulas can cause skin breakdown, particularly around the ears where the tubing or mask straps may rest. Regular checks for any signs of skin breakdown are essential for early detection and prevention.

A. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.

Incorrect options:

B. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.

C. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.

D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.