A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

A) Place the client close to the nurses' station:

While placing the client closer to the nurses' station may enhance supervision and monitoring, it does not address the immediate safety concern of preventing the client from removing the IV catheter again. This action may be considered after implementing measures to prevent further self-harm.

B) Cover the site with a stockinette dressing:

Covering the site with a dressing is important for maintaining a sterile environment around the IV site. However, if the client is disoriented and has already removed the IV catheter, simply covering the site may not prevent further attempts to remove it. Addressing the underlying issue of the client's behavior is necessary.

C) Administer a sedative:

Administering a sedative may be appropriate in certain situations to calm an agitated or disoriented client. However, it should not be the first action taken after observing the reinsertion of the IV catheter. Sedation should be used judiciously and only after other interventions to ensure the client's safety have been attempted.

D) Apply a soft mitten restraint:

This is the most appropriate action to prevent the client from removing the IV catheter again. A soft mitten restraint limits the client's ability to access the IV site while allowing some movement and comfort. It is a temporary measure to ensure the safety of the client and the integrity of the IV line until further assessment and interventions can be implemented.

A) ADL (Activities of Daily Living): This abbreviation is commonly used in healthcare documentation to refer to the routine tasks individuals perform independently for self-care, such as bathing, dressing, grooming, and toileting. Reminding the newly licensed nurse to use the abbreviation ADL ensures clear and concise documentation of the client's functional status and care needs.

B) SQ: While SQ could stand for subcutaneous (as in SQ injection), it's generally recommended to use the full term "subcutaneous" in documentation to avoid confusion or misinterpretation. Using abbreviations like SQ can lead to errors or miscommunication in healthcare settings.

C) AU: This abbreviation typically stands for "each ear" when documenting information related to the ears, such as when administering eardrops or assessing for symptoms. However, similar to SQ, it's preferable to use the full term "each ear" in documentation to ensure clarity and avoid ambiguity.

D) HS: HS commonly stands for "hour of sleep" or "at bedtime" when documenting medication administration times. However, like other abbreviations, it's advisable to use the full term "at bedtime" to prevent misunderstandings or errors related to medication dosing schedules.