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Report the finding to the healthcare Study with Quizlet and memorize flashcards containing terms like B Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Study with Quizlet and memorize flashcards containing terms like The nurse observes that a male client has removed the covering from an ice pack applied to his knee. Which should Study with Quizlet and memorize flashcards containing terms like An emergency department nurse is interviewing a female client who has a history of epilepsy with tonic-clonic seizures controlled by phenytoin (Dilantin). 100% (8) 27. What is the priority nursing Study with Quizlet and memorize flashcards containing terms like 71. The nurse has been alerted by the EMR Nursing 1st Semester HESI Standardized Test Learn with flashcards, games, and more — for free. 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