A nurse is caring for a client in an outpatient clinic.

Exhibits

Complete the following sentence by using the lists of options. The client is at highest risk for developing

dropdown

evidenced by the client's

dropdown

A. Place the client in a sitting position. A belt restraint should be applied while the client is in a sitting or supine position to minimize the risk of injury and ensure comfort. Proper positioning helps maintain respiratory function and circulation, reducing complications associated with prolonged immobility.
B. Ensure the restraint is placed across the client's chest. A belt restraint should be secured around the waist, not the chest, to prevent respiratory restriction. Placing it across the chest can impair breathing and increase the risk of asphyxiation, especially if the client struggles or shifts position.
C. Tie the restraint to the railing of the client's bed. Restraints should always be secured to the bed frame, never to the side rails, to prevent injury. Attaching restraints to side rails can cause excessive restriction or accidental tightening if the rails are adjusted, leading to discomfort or harm.
D. Apply the restraint under the client's clothes. Restraints should be placed over the client's clothing or gown to prevent skin irritation and pressure injuries. Applying a restraint directly against the skin increases the risk of friction, breakdown, and potential pressure ulcers over time.

A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.