A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home.
Which of the following actions should the nurse take?

Answer is: b. Document the client's condition every 15 min.

Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.

Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.

Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.

Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.

Choice A rationale:

Spotting is a common finding in placenta previa. It occurs due to the abnormal implantation of the placenta over or near the cervical os, leading to vaginal bleeding. This bleeding can range from mild spotting to severe hemorrhage and is a significant sign of placenta previa.

Choice B rationale:

Nausea is not a specific sign of placenta previa. Nausea and vomiting are common symptoms during early pregnancy but are not directly related to placenta previa.

Choice C rationale:

A board-like abdomen is a sign of peritonitis or an acute abdomen, which is not associated with placenta previa. This finding suggests intra-abdominal inflammation and is unrelated to the condition in question.

Choice D rationale:

Delayed menses is a common sign of pregnancy, but it does not specifically indicate placenta previa. Placenta previa is characterized by vaginal bleeding, which is not synonymous with a delay in menstrual periods.