A nurse is assessing the impact of stressors on a family. Which of the following should indicate to the nurse there has been a change in family system?

A. Place the client in a supine position: The position should prioritize the client’s safety and comfort, considering their condition and the risk of aspiration or discomfort. A supine position may not be the most appropriate for this client’s agitation or confusion.

B. Attach the straps to the side rails of the bed frame: Attaching the restraints to the side rails could be dangerous, as it may cause injury or further agitation. Restraints should be attached to a non-movable part of the bed to ensure the client’s safety and prevent injury due to entrapment.

C. Secure the straps with a square knot: Restraints should not be secured with a square knot, as this could make them difficult to release quickly in an emergency. Instead, the restraint should be fastened in a way that allows for quick removal when needed to ensure the client's safety.

D. Remove the restraints every 2 hr: It is essential to remove restraints at least every 2 hours to check for any signs of injury, provide comfort, and ensure circulation. Removing restraints allows for proper skin care and reduces the risk of complications like pressure ulcers.

A. Read the medication label twice prior to administration: Best practice requires reading the label three times (when retrieving, preparing, and before administering), so reading it only twice is insufficient for safety.

B. Ask the client if they have ever taken a similar medication: While helpful, this does not replace the need for the nurse to verify the medication's action, side effects, and interactions independently.

C. Use one patient identifier prior to medication administration: Safe practice requires using two patient identifiers (e.g., name and date of birth), so using only one is inadequate and unsafe.

D. Access the online drug formulary for an unfamiliar medication: This ensures the nurse understands the medication's purpose, dosage, side effects, and contraindications, which is critical for safe first-time administration.