A nurse is assisting in the care of a client who has pneumonia in the medical unit.

Exhibits

Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)

Choice A rationale

Assessing pain levels is a nursing task requiring clinical judgment, which is beyond the scope of an assistive personnel's duties.

Choice B rationale

Checking an IV site for redness or swelling also requires clinical assessment skills, which are tasks for the nurse.

Choice C rationale

Measuring intake and output is a routine task that can be safely delegated to an assistive personnel. It involves straightforward measurement and recording.

Choice D rationale

Reinforcing teaching about crutch-gait walking requires specific patient education, which falls under the nurse's responsibilities.

Choice A rationale

Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.

Choice B rationale

Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.

Choice C rationale

A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.

Choice D rationale

Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.

Choice E rationale

Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.