A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.

A. Hyperglycemia: Albuterol is not prescribed to manage blood glucose levels. While it can sometimes cause a mild increase in blood glucose as a side effect, its primary therapeutic action is not directed at treating hyperglycemia or any diabetic conditions.

B. Swelling of the lips: Swelling of the lips could indicate an allergic reaction or angioedema, which is a medical emergency. Albuterol is not used to treat allergic swelling; epinephrine would be the medication of choice in managing severe allergic reactions or anaphylaxis.

C. Nausea: Albuterol is not intended to treat nausea. Although gastrointestinal upset, including nausea, can sometimes occur as a side effect of albuterol, it is not administered for the purpose of controlling nausea in clients.

D. Shortness of breath: Albuterol is a short-acting beta2-agonist that works by relaxing bronchial smooth muscle, leading to bronchodilation. It is commonly prescribed to relieve acute episodes of shortness of breath, wheezing, or bronchospasm, particularly in asthma or COPD.