A nurse is recording the intake and output (I&O) for a client.

The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits.

Which volume should the nurse record on the I&O?

Choice A rationale

Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.

Choice B rationale

Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.

Choice C rationale

A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.

Choice D rationale

Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.

Choice E rationale

Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.

The nurse should first: Response 1: Notify the primary health care provider immediately.

This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.

Then, the nurse should: Response 2: Start an IV line for potential medication administration.

Starting an IV line ensures that the client can receive any necessary medications quickly.