The nurse is planning care for a client who is experiencing confusion. When considering safety promotion, the nurse plans to:
1. Keep the windows in the client's room closed.
2. Keep the side rails up on the bed when the client is alone.
3. Administer ordered medication.
4. Place the call bell on the bedside table.
2. Keep the side rails up on the bed when the client is alone.
Rationale:
To prevent falls in the confused client, the nurse should keep the bed rails up when the client is alone. Most agency windows are kept close or are the type that cannot open wide enough to cause injury. Administering ordered medication will not prevent injury to the client. The call bell should be placed next to the client in the bed so that the client does not fall trying to reach the bedside table.
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