A nurse administered an IM injection to a client. Which of the following actions should the nurse take to reduce the risk of a needlestick injury?

A. Documenting in the client's medical record every 15 minutes is essential to monitor the client's status, including physical and psychological well-being, while in restraints. Accurate documentation ensures that any changes or responses to the intervention are recorded and communicated to other healthcare providers.
B. Offering toileting to the client every 4 hours may be necessary depending on the client's

individual needs, but it does not address the immediate need for monitoring the client's safety and well-being while restrained.
C. Removing the restraint when the client falls asleep is not appropriate without a healthcare provider's order. Restraints should only be removed based on a specific criteria set forth by
institutional policies or as directed by the healthcare provider.

D. Requesting an as-needed prescription for restraints is not appropriate. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a healthcare provider's assessment and orders.

A. While reassurance is important, simply telling the client that she will adjust to changes to her body may minimize her concerns and not adequately address her emotional needs. It's important to offer support and provide resources to help the client cope with potential changes.
B. While an occupational therapist may be able to provide valuable support, their role may not specifically address the client's concerns about body image changes related to breast cancer treatment.
C. Reach to Recovery is a program offered by the American Cancer Society that connects newly diagnosed breast cancer patients with trained volunteers who have experienced breast cancer themselves. These volunteers can offer support, guidance, and practical tips for coping with the physical and emotional challenges of breast cancer diagnosis and treatment. Initiating a referral to this program can provide the client with valuable support from someone who has been through a similar experience.
D. While surgery may be an option for restoring the appearance of the breast, it may not fully address the client's concerns about potential changes to her body image. Additionally, not all breast cancer patients undergo surgery or choose reconstructive procedures, so it's important to provide support and resources regardless of the treatment chosen.