A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?

Rationale:
A. Discuss future treatment options with the client's health care surrogate: The client has decision-making capacity and advance directives in place, so the nurse should honor the client’s wishes rather than deferring to the surrogate.

B. Encourage the client to complete a final hemodialysis treatment: Encouraging treatment contradicts the client’s expressed wishes and advance directives, violating the client’s autonomy and right to refuse care.

C. Contact the client's family to discuss the decision: Family input may be supportive, but the client’s decisions take priority. Involving the family without the client’s consent may undermine autonomy.

D. Discuss possible options for discharge with the client: The nurse should focus on supporting the client’s choices, including end-of-life care and hospice or palliative services, and discuss discharge options that align with the client’s wishes.

Rationale:
A. Remove the restraints from the client: Restraints should be discontinued as soon as the client no longer poses a danger to themselves or others. Prompt removal prevents unnecessary restriction and respects the client’s rights and dignity.

B. Offer the client PRN pain medication: While assessing for discomfort is important, pain medication is not the immediate priority once the client is calm and cooperative, unless the client requests it or shows signs of pain.

C. Continue to monitor the client every 15 min: Monitoring should continue after restraint removal according to facility policy, but the first action is to remove the restraints to avoid unnecessary confinement.

D. Encourage the client to attend a group therapy session: While therapeutic activities are important, this is not the immediate action following restraint use. Ensuring the client’s safety and removing restraints takes priority.