A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.

The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.

The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.

The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.

A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.

B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.

C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.

D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.