A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Choice A Reason: Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling. Choice B Reason: Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently. Choice C Reason: Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate. Choice D Reason: Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.