A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level.

Which of the following responses should the nurse make?

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

The nurse should take the following actions when receiving a telephone prescription from a client's provider:

1. Ask the provider to spell out the name of the medication: This is important to ensure accurate transcription of the medication name. Spelling out the name helps prevent errors due to similar-sounding medications or confusion with abbreviations.
2. Request that the provider confirm the read-back of the prescription: This step ensures that the nurse and the provider are on the same page and that the prescription has been accurately transcribed. It allows for verification and correction if any discrepancies are identified.
3. Record the date and time of the telephone prescription: Documenting the date and time of the telephone prescription is essential for tracking and reference purposes. It helps establish a clear timeline of events and ensures proper documentation of the medication order.

It is not necessary to withhold the medication until the provider signs the prescription, as telephone prescriptions are typically followed up with a written prescription or electronic verification.

Instructing another nurse to record the prescription in the medical record may not be necessary, as the nurse who received the telephone prescription is responsible for accurately documenting the order in the medical record. However, if necessary, the nurse can delegate the task of documentation to another qualified staff member under their supervision, ensuring accuracy and completeness.