A client with dehydration is being weighed on a standing scale next to the bed. The most important action by the nurse is to
a. assist the client to prevent falls.
b. calibrate the scale per manufacturer's directions.
c. document the weight and compare it with prior ones.
d. explain to the client what is going to happen.
A
All options are valid activities by the nurse, or by the unlicensed assistive personnel who may be weighing the client. However, client safety comes first, so the most important action by the nurse is to assist the client, who may have orthostatic hypotension, so as to prevent falls.
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