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 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.

Choice A reason:

Increased haemoglobin is correct. level Epoetin alfa is a medication used to stimulate the production of red blood cells in the bone marrow, and it is often prescribed to treat anaemia. Anaemia is characterized by a decrease in the number of red blood cells or a decrease in the amount of haemoglobin, which is responsible for carrying oxygen in the blood.

The therapeutic response to epoetin alfa is an increase in the haemoglobin level. This indicates that the medication is effectively stimulating the production of red blood cells, leading to an improvement in the client's anaemia and overall oxygen-carrying capacity of the blood.

Choice B reason:

Increased platelet count: Platelets are involved in blood clotting and are not directly affected by epoetin alfa.

Choice C reason:

Increased neutrophil count: Neutrophils are a type of white blood cell involved in the body's immune response. Epoetin alfa primarily affects red blood cells and does not directly impact white blood cell levels.

Choice D reason:

Increased erythrocyte sedimentation rate (ESR): ESR is a non-specific indicator of inflammation in the body and is not directly related to the therapeutic response of epoetin alfa in treating anaemia.