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Raise the height of the client's bed: Raising the bed too high can increase the risk of falls. The bed should be at a safe working height for the nurse and low enough for the client to place their feet on the floor.

Place the chair at a 90° angle to the bed: The chair should be placed at a 45° angle to the bed on the client's strong side (right side in this case) to make the transfer easier.

Place the chair on the client's left side: Since the client has left-sided weakness, the chair should be placed on the right (strong) side to facilitate a safer and easier transfer.

Supine: The client lies flat on their back with no tilt. This position does not help mobilize secretions from the lower lungs.

Fowler's: The client is in a semi-sitting position (head elevated). This is used for breathing ease but not effective for postural drainage.

Sims': This is a semi-prone position used for enema administration or rectal examinations, not for mobilizing lung secretions.

"I will place an area rug at the entry of my bathroom.": Area rugs are fall hazards and should be removed.

"I will keep the fluorescent ceiling light on in my room at night.": While keeping lights on is helpful, ceiling lights may be too bright or not easily accessible. A night light or bedside lamp is safer and more practical.

“I will keep my walker at the end of my bed.": The walker should be kept within reach to ensure it is easily accessible when the client gets out of bed.

Muscle mass: Passive ROM does not build muscle mass because the muscles are not actively used.

Muscle strength: Muscle strength increases with active, not passive, exercises.

Bone density: Bone density is improved through weight-bearing and resistance exercises, not passive motion.

Stress: Stress can cause headaches and fatigue, but not vertigo or cherry-red mucosa.

Septic shock: Septic shock typically presents with hypotension, fever or hypothermia, and poor perfusion-not cherry-red mucosa.

Heat stroke: Heat stroke causes high body temperature, altered mental status, and dry skin-not related to furnace use or cherry-red mucosa.

The client has a capillary refill of 1 second: This is a normal finding and indicates adequate perfusion.

The client has full range of motion in her wrist: This is a positive finding, not a complication.

The client is attempting to remove the restraint: This suggests agitation or discomfort but not necessarily a physical complication like impaired circulation.

Inserts one finger between the client's wrist and the restraint: Best practice is to allow two fingers of space to ensure adequate circulation and comfort.

Ties the restraints to the side rails: Restraints must never be tied to movable parts (like side rails); they should be secured to the bed frame.

Ties the straps of the restraints in a double knot: Double knots are hard to remove in emergencies; a quick-release knot is recommended.

Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: It is typically defined by a drop of ≥10 mm Hg diastolic or ≥20 mm Hg systolic.

Orthostatic hypotension increases a client's risk of a pulmonary emboli: Orthostatic hypotension does not cause PE; they are unrelated pathophysiologies.

Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: The correct threshold is ≥20 mm Hg systolic.

Hyperextension: Hyperextension is movement of a joint beyond its normal range-away from the body’s midline, typically backward.

Circumduction: Circumduction refers to circular movement combining flexion, extension, abduction, and adduction.

Internal rotation: This refers to turning the limb inward around its axis, not toward the midline.