A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

The correct answer is C. "Close your mouth around the mouthpiece." The rationale for this instruction is that it ensures that the medication reaches the lungs and does not escape through the mouth or nose. Albuterol is a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs. It is used to treat or prevent bronchospasm, or narrowing of the airways, in people with asthma or certain types of chronic obstructive pulmonary disease (COPD). It is also used to prevent exercise-induced bronchospasm. Albuterol is delivered through a metered dose inhaler (MDI), which is a device that releases a measured amount of medication with each puff. To use an albuterol MDI correctly, the client should follow these steps :

• Shake the inhaler well before each spray.
• Remove the cap and look at the mouthpiece to make sure it is clean.
• Breathe out fully.
• Put the mouthpiece between your lips and close your mouth around it.
• Press down on the inhaler to release the medication as you start to breathe in slowly.
• Breathe in slowly and deeply over 3 to 5 seconds.
• Hold your breath for 10 seconds to allow the medication to reach your airways.
• Breathe out slowly.
• If you need another puff, wait 1 minute and repeat steps 4 to 8.

The correct answer is choice D. Document the client’s condition after every 15 minutes.

Choice A rationale:

Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used as a last resort and not on a PRN basis. Restraints should be used only when necessary to ensure the safety of the patient and others, and always with a specific, time-limited order.

Choice B rationale:

Removing the client’s restraint every 4 hours is not frequent enough. Restraints should be removed more frequently to assess the patient’s condition, provide care, and ensure that the restraint is still necessary.

Choice C rationale:

Attaching the restraint to the bed’s side rails is unsafe. Restraints should be attached to a part of the bed frame that moves with the patient to prevent injury.

Choice D rationale:

Documenting the client’s condition every 15 minutes is the correct guideline. Frequent documentation ensures that the patient’s condition is continuously monitored, and any changes can be addressed promptly to ensure safety and well-being.