A nurse in an outpatient surgical center is assisting in the care of a client.

Exhibits

Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

A. An assistive personnel raises all four side rails of a client's bed before leaving the room: Raising all four side rails can be considered a form of restraint and poses a safety risk, especially if the client attempts to climb over them. It can increase the risk of falls and injury, particularly in confused or restless clients.

B. An assistive personnel places a weight-sensitive sensor mat on the mattress beneath a client's buttocks: This is not a safety hazard; it's a fall prevention measure. These sensor mats are designed to alert staff when a client attempts to get up, helping prevent falls in at-risk individuals.

C. A client who has bilateral wrist restraints has a capillary refill of less than 2 seconds:
A capillary refill of less than 2 seconds is within normal limits and indicates that circulation to the hands is intact. This suggests that the restraints are not too tight and do not currently pose a circulatory risk to the client.

D. A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site: A mild buzzing or tingling sensation is an expected and normal effect of a TENS unit. It does not indicate a malfunction or a safety issue unless it becomes painful or the skin shows signs of irritation or burns.

Rationale for Correct Answers:

• Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
• Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

• Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
• Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
• Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.