🩸 Orthostatic hypotension increases the risk of falls because a sudden drop in blood pressure when changing positions can decrease blood flow to the brain.

🩸 Clients may experience dizziness, lightheadedness, weakness, or fainting when moving from lying or sitting to standing.

🩸 These symptoms can cause loss of balance and increase the likelihood of injury from falls.

🩸 Nurses should teach clients to change positions slowly, sit at the bedside before standing, and use assistance if needed.

🩸 Older adults and clients taking antihypertensive medications are at increased risk for orthostatic hypotension.

🩸 Safety interventions such as fall precautions and monitoring blood pressure changes help reduce complications.

🩸 Orthostatic hypotension is diagnosed by assessing blood pressure and heart rate changes with position changes.

🩸 Therefore, the correct teaching point is that orthostatic hypotension increases a client's risk of a fall.

🦯 Moving the left foot forward first is correct because the client has left-sided weakness, and the weak extremity should move with the cane to provide maximum support.

🦯 The client should hold the cane on the stronger side (right side) to improve balance and provide support for the weakened left leg.

🦯 The proper sequence is to move the cane forward first, then the weak leg, followed by the stronger leg.

🦯 This pattern helps redistribute weight and reduces the risk of falls.

🦯 Teaching proper cane use is especially important for older adults who may already have increased fall risk.

🦯 The nurse should ensure the cane height allows slight elbow flexion for safe and effective use.

🦯 Correct technique promotes independence and safer ambulation.

🦯 Therefore, the nurse should instruct the client to move the left foot forward first when walking.

💪 Asking the client to push her feet against the nurse’s palms is the correct action because it directly assesses lower extremity muscle strength before ambulation.

💪 Manual muscle testing evaluates the client’s ability to generate force against resistance.

💪 Assessing leg strength helps determine whether the client can safely stand, transfer, and walk.

💪 Weakness in the lower extremities increases the risk of falls and injury during ambulation.

💪 The nurse should compare strength on both sides of the body to identify weakness or asymmetry.

💪 This assessment is especially important for clients with mobility limitations or neurological conditions.

💪 Determining strength helps the nurse choose appropriate assistance and safety measures.

💪 Therefore, the nurse should ask the client to push her feet against the nurse’s palms.

🦯 This statement indicates the client needs further teaching because crutches must be individually fitted to the client’s height and body size.

🦯 Using another person’s crutches can cause improper positioning, decreased stability, and increased risk of falls.

🦯 Incorrect crutch height can place pressure on the axilla (armpit), potentially causing nerve compression and injury.

🦯 The nurse should teach the client to use only properly fitted crutches prescribed or adjusted for them.

🦯 Proper fit allows the client to support weight through the hands while maintaining safe posture and mobility.

🦯 Safety equipment should always match the individual user’s needs.

🦯 Therefore, borrowing a family member’s crutches indicates a need for additional teaching.

🦵 Measuring from the heel to the popliteal space is the correct action because knee-high antiembolic stockings must extend from the foot to just below the knee.

🦵 The popliteal space is the area behind the knee where the stocking should end for proper fit and compression.

🦵 Accurate measurement ensures the stocking provides effective pressure to promote venous return and prevent venous stasis.

🦵 Incorrect sizing can result in ineffective compression or impaired circulation.

🦵 Antiembolic stockings are used to reduce the risk of deep vein thrombosis (DVT) in clients with decreased mobility.

🦵 The nurse should also measure leg circumference according to manufacturer guidelines to ensure proper sizing.

🦵 Proper application helps prevent pooling of blood in the lower extremities.

🦵 Therefore, the nurse should measure from the heel to the popliteal space.

🦵 Measuring from the heel to the popliteal space is the correct action because knee-high antiembolic stockings must extend from the foot to just below the knee.

🦵 The popliteal space is the area behind the knee where the stocking should end for proper fit and compression.

🦵 Accurate measurement ensures the stocking provides effective pressure to promote venous return and prevent venous stasis.

🦵 Incorrect sizing can result in ineffective compression or impaired circulation.

🦵 Antiembolic stockings are used to reduce the risk of deep vein thrombosis (DVT) in clients with decreased mobility.

🦵 The nurse should also measure leg circumference according to manufacturer guidelines to ensure proper sizing.

🦵 Proper application helps prevent pooling of blood in the lower extremities.

🦵 Therefore, the nurse should measure from the heel to the popliteal space.

Shave the client's hair in the direction of the hair growth

🛁 Shaving in the direction of hair growth helps reduce the risk of skin irritation, cuts, and razor burns.

🛁 Clients who are immobile may have fragile skin and require careful hygiene practices.

🛁 Proper shaving technique promotes comfort and protects skin integrity.

🛁 The nurse should use gentle strokes and avoid applying excessive pressure.

Check for personal items when changing the bed linens

🛁 Checking for personal items while changing linens helps prevent loss of the client’s belongings.

🛁 Immobile clients may be unable to retrieve items independently if they are misplaced.

🛁 This action supports client safety, dignity, and respect for personal property.

🛁 Nurses should maintain awareness of valuables and personal items during care.

🫁 Assessing the client's respiratory status is the correct first action because the nurse must determine the client's current need for suctioning before performing the procedure.

🫁 Assessment includes evaluating respiratory rate, breath sounds, oxygen saturation, work of breathing, and presence of secretions.

🫁 Suctioning is an invasive procedure that should only be performed when indicated to avoid unnecessary airway irritation and hypoxia.

🫁 The nurse must identify whether the client is experiencing airway obstruction or difficulty clearing secretions.

🫁 After assessment confirms the need, the nurse can proceed with positioning, equipment preparation, and oxygenation measures.

🫁 Performing interventions without first assessing the client may expose the client to unnecessary risks.

🫁 A systematic airway assessment promotes safe and effective tracheostomy care.

🫁 Therefore, the nurse should assess the client's respiratory status first.

🫁 Attaching a humidifier bottle is the correct action because oxygen delivered at higher flow rates, such as 5 L/min, can dry the client’s airway and nasal mucosa.

🫁 Humidification adds moisture to the oxygen, helping prevent dryness, irritation, and discomfort of the respiratory tract.

🫁 Clients receiving oxygen therapy through a nasal cannula at higher flow rates benefit from humidified oxygen.

🫁 The nurse should ensure the humidifier bottle is filled with sterile water according to facility policy and connected correctly.

🫁 Maintaining airway comfort improves tolerance of oxygen therapy and supports effective respiratory care.

🫁 Pneumonia can already cause airway irritation and increased respiratory secretions, making humidification beneficial.

🫁 Proper oxygen administration helps improve oxygenation while minimizing complications.

🫁 Therefore, the nurse should attach a humidifier bottle to the base of the flow meter.

🦯 Lowering the client to the floor is the correct action because it reduces the risk of injury when a client begins to fall during ambulation.

🦯 The nurse should not attempt to stop the fall by pulling the client upward because this can injure both the client and the nurse.

🦯 The nurse should maintain a wide base of support, bend the knees, and guide the client gently to the floor.

🦯 Protecting the client’s head and controlling the descent are priorities during an assisted fall.

🦯 Safe fall techniques help prevent fractures, head injuries, and musculoskeletal injuries.

🦯 The nurse should remain with the client after the fall and assess for injury.

🦯 Proper body mechanics protect both the client and the nurse.

🦯 Therefore, the nurse should lower the client to the floor.