A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

A. A client with chronic obstructive pulmonary disease who needs guidance on incentive spirometry requires nursing judgment and education to ensure proper technique, so this task is best performed by a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires assessment and potential intervention by a nurse to address cardiac issues.

C. Assisting a client with toileting typically involves tasks such as transferring, positioning, and providing hygiene assistance, which can be safely delegated to an assistive personnel.

D. Providing a client who has awoken following a bronchoscopy with a drink involves assessing for the absence of nausea or vomiting and ensuring the client can swallow safely, which requires nursing judgment and should be performed by a nurse.

A. Failure to engraft typically presents with symptoms such as persistent neutropenia, thrombocytopenia, and anemia, rather than skin peeling.

B. Veno-occlusive disease, also known as sinusoidal obstruction syndrome, can lead to liver dysfunction and subsequent skin manifestations such as peeling, especially on the palms and soles.

C. Graft-versus-host disease (GVHD) typically presents with symptoms such as skin rash, diarrhea, and liver dysfunction, but peeling skin is not a hallmark manifestation.

D. Pancytopenia refers to a deficiency of all types of blood cells (red blood cells, white blood cells, and platelets) and is not typically associated with skin peeling as a primary symptom.