A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse
include?

A. The client has been in the restraints for 4 hr. This is incorrect because the duration of restraint use is determined by the client's behavior and safety, not a set time frame. Restraints should be discontinued as soon as they are no longer necessary.
B. The client can explain the reasons for their behavior. This is incorrect because insight into behavior does not necessarily indicate that the client is no longer a danger to themselves or others.
C. The client is able to calmly follow commands. This is correct because the primary indication for removing restraints is when the client demonstrates self-control and the ability to follow directions, reducing the risk of harm.
D. The client reports that the restraints are too tight. This is incorrect because a complaint of tight restraints indicates a need for reassessment and possible adjustment, but not necessarily discontinuation.

A. Measure and record the client's leg circumferences daily. This is correct because measuring leg circumference helps assess for changes in swelling and monitor the progression or improvement of deep-vein thrombosis.
B. Place the client with their knees in a sharply flexed position. This is incorrect because sharply flexing the knees can impede blood flow and increase the risk of clot formation. The client should be encouraged to keep their legs extended and slightly elevated.
C. Monitor the client's RBCs every 4 hr. This is incorrect because deep-vein thrombosis does not typically require frequent RBC monitoring. Instead, coagulation studies such as PT, aPTT, and INR are more relevant.
D. Administer warfarin PO daily. This is incorrect because warfarin is contraindicated during pregnancy due to its teratogenic effects. Instead, low-molecular-weight heparin or unfractionated heparin is the preferred anticoagulant during pregnancy.