The nurse is caring for a client admitted with vomiting and diarrhea after vacationing. Which of the following nursing interventions are appropriate for this client? (SELECT ALL THAT APPLY)

B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.

C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.

E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.

A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.

D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.

A. The JP drain helps prevent excessive accumulation of fluid in the wound by actively draining it away. If fluid were to accumulate excessively, it could impair wound healing and increase the risk of infection.

However, the primary purpose of the JP drain is to remove fluid rather than prevent its collection altogether.

B. The JP drain does not directly assess the degree of healing. Its primary function is to drain fluid from the wound to promote healing by preventing fluid accumulation, which could hinder healing. Assessing the degree of healing typically involves visual inspection of the wound by the healthcare provider rather than relying on the drain.

C. This is not the purpose of the JP drain. Healing generally occurs by the gradual migration of cells and tissues to close the wound, which is an internal process. The JP drain assists in the healing process by preventing complications due to fluid accumulation but does not influence healing from outside to inside.

D. While the JP drain itself does not directly prevent the entrance of microorganisms into the wound, it indirectly contributes to infection prevention by removing excess fluid. Accumulated fluid can provide a medium for bacterial growth, potentially leading to infection. By draining fluid effectively, the JP drain helps maintain a cleaner wound environment, reducing the risk of infection.