A nurse is observing a client who is in four-point restraints for violent and self-destructive behavior. Which of the following actions should the nurse take when using four-point restraints?

A. Place the client in a room with negative-pressure airflow: Negative-pressure airflow is used for airborne precautions. MRSA requires contact precautions, which include placing the client in a private room or a room with others who have the same infection.

B. Ensure visitors use a surgical mask when they enter the client's room: Surgical masks are not required for MRSA unless there is a respiratory complication. For MRSA, visitors should use gloves and gowns for contact precautions, but a mask is not necessary.

C. Remove isolation gown before removing gloves: The gown should be removed after the gloves to prevent contamination. The gloves should be removed first to avoid touching any surfaces with contaminated hands, and then the gown can be safely removed.

D. Use designated equipment that stays in the client's room: To prevent the spread of MRSA, designated equipment (such as blood pressure cuffs, stethoscopes, and thermometers) should stay in the client's room. This minimizes risk of cross-contamination and ensures infection control.

Rationale for Correct Choices:

• Oxygen saturation: The client's oxygen saturation has dropped to 90%, which is below the acceptable range of 92-100% for postoperative patients. This decrease in oxygen saturation needs immediate attention as it could indicate respiratory compromise or early signs of hypoxia.
• Behavioral findings: The client expresses a feeling of "something is wrong" and appears agitated, which may signal a complication, such as pain, anxiety, or more serious issues like internal bleeding or a developing embolism. The nurse should address the client's behavioral findings promptly to identify the cause.

Rationale for Incorrect Choices:

• Pain: The client rates incisional pain as 5 out of 10, which is moderate but not critical. While pain management is important, it is not the primary concern in this case given the client’s symptoms of agitation and decreased oxygen saturation.
• WBC count: The WBC count is mildly elevated (10,800/mm³), which could indicate a mild inflammatory response, possibly due to surgery. However, it is not as urgent as addressing the drop in oxygen saturation and the client’s behavioral changes.
• Bowel findings: Hypoactive bowel sounds are expected following abdominal surgery and are not immediately concerning. The client’s bowel status does not require urgent follow-up compared to their oxygen saturation and behavioral symptoms.