A nurse is contributing to the plan of care for a client who has a gambling disorder. Which of the following nursing interventions should the nurse include in the plan of care?

Rationale:

A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.

B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.

C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.

D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.

Rationale:

A. Search for the medication on the National Library of Medicine's MedlinePlus website: This action allows the nurse to independently access a reliable, evidence-based source to gather essential information about the medication, including its purpose, dosage, side effects, and precautions. It promotes safe and informed medication administration.

B. Ask the charge nurse to explain the purpose of the medication: While consulting experienced colleagues is acceptable, relying solely on another person without verifying the medication through a formal, credible source may lead to misinformation. Independent verification is a safer and more accountable approach.

C. Ask the client to state the indication for the medication: Clients may not always have accurate knowledge of their medications or may misunderstand the reason for their use. Relying on client input does not ensure medication safety and is not a substitute for clinical validation.

D. Allow the client to self-administer the prepared medication: Allowing a client to self-administer a medication that the nurse does not understand is unsafe and violates standards of medication administration. Nurses are responsible for knowing what they administer and ensuring it is appropriate for the client's condition.