A nurse is reinforcing teaching about end-of-life care with the partner of a client.Which of the following statements should the nurse make?

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.

Choice A rationale

A client who receives burns from a heating pad has experienced harm due to the healthcare setting or treatment. An incident report should be completed to document the injury and investigate the cause to prevent future occurrences.

Choice B rationale

A client's dissatisfaction with meal temperature does not typically require an incident report unless it leads to significant issues such as foodborne illness or other adverse effects. It is usually managed through the facility's complaint process.

Choice C rationale

If a client becomes disoriented and falls out of bed, it is crucial to complete an incident report to document the event, assess the cause, and implement measures to prevent similar incidents. This helps ensure client safety and continuous quality improvement.

Choice D rationale

When a client's visitor becomes dizzy and faints in the client's room, an incident report should be completed to document the occurrence and initiate an investigation into the cause. This helps in providing appropriate care and preventing future incidents.

Choice E rationale

A client's inability to afford recommended physical therapy is an important issue but does not typically require an incident report. This situation should be addressed through social services or financial counseling to find a solution.