A nurse assesses four patients. Which patient has greatest risk for hypomagnesemia?

Answer: B. The padding of the restraints is against the client's bony prominences.

A. The nurse can insert one finger between the client's wrist and the restraint.
The proper guideline is that the nurse should be able to insert two fingers between the client's wrist and the restraint. This ensures the restraint is snug but not too tight, which helps prevent impaired circulation and skin breakdown.

B. The padding of the restraints is against the client's bony prominences.
This is the correct practice. The padding of the restraints should always be applied to protect the client’s skin and prevent injury, particularly over bony prominences where the risk of pressure sores or skin breakdown is higher.

C. The AP ties the straps of the restraints in a double knot.
A double knot should not be used because it can make it difficult to quickly release the restraint in an emergency. A quick-release knot should always be used to ensure the restraint can be removed easily and promptly if needed.

D. The AP ties the restraints to the side rails.
Restraints should never be tied to movable parts like side rails, as raising or lowering the side rails could cause injury. Restraints should be secured to a part of the bed frame that does not move to prevent harm to the client.

A. Contact the provider for further orders:
Contacting the provider for further orders might delay the administration of blood, which is crucial in situations where there is an urgent need, such as severe bleeding or anemia. Given that the unit of blood available is type O negative, which is universally compatible with most recipients in emergency situations, waiting for further orders could jeopardize the client's health.
B. Complete an incident report:
There is no incident or error that occurred in this situation. Using type O negative blood for a recipient with type A positive blood is an accepted practice in emergencies, and therefore, does not warrant the completion of an incident report.
C. Administer the blood as ordered:
Type O negative blood can be safely administered to recipients with any blood type in emergency situations. Since the client requires blood, and the unit available is type O negative, which is universally compatible, administering the blood as ordered is the appropriate action to ensure timely treatment.
D. Notify the blood bank:
Notifying the blood bank is unnecessary in this situation. The nurse has a unit of type O negative blood on hand, which is appropriate for immediate administration to the client with type A positive blood. There's no need to inform the blood bank as the blood is compatible and can be safely administered.