Share This Link

Ensuring that four fingers fit between the restraint and the client's body helps prevent excessive tightness, which can lead to restricted circulation and skin breakdown. This action promotes client safety and comfort.

Checking the client's skin integrity every 4 hours is an essential nursing intervention, but it does not specifically address the proper application of the restraint.

Tying the belt restraint to the side rail of the bed may pose a safety risk, as it could restrict the client's movement and lead to injury or discomfort.

Increasing protein intake is not directly related to preventing orthostatic hypotension. While adequate nutrition is essential for overall health and healing postoperatively, it does notspecifically address the risk of orthostatic hypotension.

Using an incentive spirometer is beneficial for promoting lung expansion and preventing respiratory complications after surgery but does not directly address orthostatic hypotension.

Performing regular isometric exercises may help prevent muscle atrophy and maintainstrength during periods of immobility but does not specifically address orthostatic hypotension.

Completing an incident report about the breach of confidentiality may be necessary, but itshould not be the first action. The immediate concern is addressing the behavior and reminding the nurse of proper protocol.

While it may be true that permission from the risk manager is required to access certainrecords, this response does not address the immediate issue of the unauthorized access. It's more important to address the behavior directly.

Contacting facility security to remove the nurse from the unit may be excessive at this stage and should be considered if the behavior persists after reminders about proper protocol.

Securing the restraints with a square knot may be too tight and could restrict circulation or cause injury. Using a quick-release knot is preferable to allow for quick removal if necessary.

While it is important to assess the client's range of motion regularly, this action does not directly address the proper application of the restraints.

Requesting a prescription renewal from the provider every 36 hours may be necessary according to facility policy, but it does not directly address the proper application of therestraints.

Eating apples and black-eyed peas is not typically associated with impaired bowelelimination. In fact, these foods are often considered high in fiber, which can promote regular bowel movements.

Drinking an adequate amount of water daily is generally beneficial for bowel health and can help prevent constipation.

Drinking coffee in moderation may have a mild laxative effect for some individuals and is not necessarily indicative of impaired bowel elimination.

While a respiratory therapist may be involved in the care of a client with dysphagia, their primary focus is on respiratory function rather than swallowing difficulties.

A registered dietitian may be involved in the client's care to provide guidance on appropriate nutrition and dietary modifications, but they do not typically specialize in the assessment andtreatment of dysphagia.

An occupational therapist may be involved in the client's care for other aspects ofrehabilitation, such as activities of daily living and upper extremity function, but they do not typically specialize in the assessment and treatment of dysphagia.

While obtaining consent from the client is ideal, it may not be appropriate if the client is unable to understand and make an informed decision due to their developmental disability.

The provider cannot sign the consent form in place of the legal guardian or the patient, as this would be a conflict of interest.

Postponing an emergency procedure that is necessary to save the client's life is not appropriate. In such cases, the surgery should proceed under implied consent.

Limiting snacks between meals may further decrease the client's overall food intake, which could exacerbate the risk of malnutrition.

Restricting visitors during meals may lead to social isolation and could interfere with the client's enjoyment of mealtime, potentially further reducing food intake.

Providing the client with three large meals each day may be overwhelming and may not align with the client's preferences or eating habits. Offering smaller, more frequent meals throughoutthe day is often more manageable for individuals with dementia.

Rhinitis, or inflammation of the nasal passages, is not typically associated with IV antibiotic administration and is not a life-threatening emergency.

Small, raised vesicles over the body may indicate a rash or allergic reaction, but unless accompanied by other severe symptoms such as difficulty breathing or systemic signs of anaphylaxis, it does not require immediate reporting.

Itching of the skin may indicate a mild allergic reaction, but unless accompanied by more severe symptoms, it does not require immediate reporting.

This response may be perceived as judgmental or dismissive of the client's autonomy and decision-making capacity. It does not provide support or address the client's emotional or psychosocial needs.

Delaying the discussion may leave the client feeling unsupported or uncertain about theirdecision. It's important to address the client's concerns and provide support in a timely manner.

This response minimizes the client's concerns and does not offer support or encouragement for discussing their decision with loved ones. It may also convey a lack of empathy orunderstanding of the client's situation.