A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

Choice A reason: Evaluating restraint need requires nursing judgment, beyond assistive personnel scope. It involves assessing behavior and alternatives, reserved for licensed staff only.

Choice B reason: Circulation checks demand clinical assessment skills, like pulse and color evaluation. This exceeds assistive personnel training, requiring a nurse’s expertise instead.

Choice C reason: Educating family about restraints involves explaining medical rationale, a nursing role. Assistive personnel lack authority to provide such detailed clinical instruction.

Choice D reason: Assisting with range-of-motion exercises is within assistive personnel scope. It supports mobility under nurse direction, safely maintaining hand function in restraints.

Choice A reason: Injecting 15 units of air into regular insulin balances vial pressure, per protocol. This step precedes drawing regular insulin, ensuring accurate mixing sequence.

Choice B reason: Withdrawing NPH now skips regular insulin prep, risking contamination or error. Air injection into both vials comes first in standard insulin administration.

Choice C reason: Verification is key but follows insulin preparation. Air injection sequence precedes dosage checks, making this premature before completing vial prep steps.

Choice D reason: Capping the needle halts the process prematurely. Air must be injected into both vials first to maintain sterile technique and accurate dosing.