A nurse is caring for an older adult client who has a hearing aid.Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Choice A rationale

Padding bony prominences helps prevent skin breakdown and pressure ulcers, which are critical considerations when using restraints to avoid additional complications for the client.

Choice B rationale

Tying restraints to the bed rail is unsafe because it can lead to injury if the bed rail is moved. Restraints should be tied to the bed frame to prevent accidental harm.

Choice C rationale

Using a square knot for restraints is inappropriate as it is difficult to untie quickly in an emergency. Quick-release knots are recommended for safety and efficiency.

Choice D rationale

Observing the client's skin integrity every 2 hours is essential to detect early signs of skin breakdown and take preventive actions to ensure the client's comfort and safety.

Choice E rationale

Ensuring that two fingers can fit between the restraint and the client ensures that the restraint is not too tight, allowing for circulation and reducing the risk of injury.

Choice A rationale

Verbal consent alone is not sufficient for invasive procedures like urinary catheter insertion. Documented consent is necessary to ensure legal and ethical compliance.

Choice B rationale

Having another nurse co-sign the consent does not verify the client's explicit agreement to the procedure. It is important that the client’s direct consent is documented.

Choice C rationale

Checking the medical record for a previous consent form may not reflect the client's current willingness. Consent should be obtained fresh to confirm current understanding and agreement.

Choice D rationale

Witnessing the client's signature on a consent form ensures that the client has been informed and agrees to the procedure, fulfilling both legal and ethical requirements.