Select words from the choices below to fill in each blank in the following sentence.

To further evaluate the client, the nurse anticipates the client will need

____

and

____

.

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) The client’s vital signs are checked every 8 hr: While vital signs are an important aspect of the client's health, this information is routine and doesn't provide new insights that would impact the overall plan of care during an interprofessional team meeting. It’s important to focus on changes in the client’s condition or specific concerns that require collaboration.

B) The client has developed difficulty ambulating: This is critical information to share during the interprofessional team meeting because it may require input from physical therapists, occupational therapists, or other specialists. Difficulty ambulating can indicate a need for reassessment of the client's mobility plan, and other team members need to be informed to develop appropriate interventions.

C) The client has state-sponsored health insurance: While the client’s insurance status is relevant for financial and discharge planning, it is not directly related to the clinical management or care coordination that would be discussed in an interprofessional team meeting. The focus should be on the client’s clinical condition and needs.

D) The client's next dressing change is scheduled in 4 hr: Although the dressing change is important for continuity of care, this is more of a task-related detail rather than critical clinical information that requires interprofessional discussion. The focus in a team meeting should be on the client's progress, challenges, and needs, not just routine care tasks.