A nurse is assisting with the care of a client on a medical surgical unit who was admitted from the emergency department.

Exhibits

For each assessment finding on Day 2 click to specify if the finding is due to lisinopril, carvedilol, or furosemide. Each finding may be related to more than 1 medication.

A. Evaluate the need for the client to remain in mitten restraints. Assessing the necessity of restraints is a nursing responsibility that requires clinical judgment. Nurses must evaluate the client's condition and determine if restraints can be discontinued or if alternative measures are appropriate.
B. Assist the client with range-of-motion exercises of the hands. Assistive personnel (AP) can perform tasks that promote mobility, such as passive or active range-of-motion exercises. These exercises help prevent stiffness and maintain circulation in restrained extremities.
C. Determine the circulation status of the affected extremities every 2 hr. Assessing circulation involves evaluating capillary refill, skin color, temperature, and sensation, which requires nursing assessment skills. This task should be performed by a nurse rather than delegated to an AP.
D. Instruct the client's family about the purpose of mitten restraints. Educating the family on medical interventions falls within the nurse’s scope of practice. The nurse must explain the rationale, risks, and alternatives to ensure family members understand the need for restraints.

A. The client's extremity should be elevated after the cast is applied. Elevating the extremity above heart level for the first 24 to 48 hours reduces swelling and prevents complications such as compartment syndrome. Ice packs can also be applied to minimize edema.
B. The client should keep the cast covered until it is dry. Covering a wet plaster cast can trap moisture and delay drying, increasing the risk of weakening the cast and skin irritation. Plaster casts should be left uncovered to allow proper air drying.
C. The client can shower with the cast after 24 hr. Plaster casts are not waterproof and should be kept dry at all times. If exposed to water, they can lose their shape and strength, potentially leading to improper healing. A plastic covering should be used when bathing.
D. The client should use a hair dryer on a warm setting to relieve itching inside the cast. Direct heat can weaken the plaster and cause burns. Instead, clients should use a cool hair dryer setting or tap lightly on the cast to manage itching without compromising its integrity.