A nurse in a provider's office is caring for a client.

Complete the following sentence by using the lists of options.

The first action the nurse should take is

____

followed by

_____

.

A. Applying a vest restraint daily at bedtime is inappropriate because restraints should only be used as a last resort when other interventions have failed. Restraints must be ordered based on ongoing assessment rather than routine use, as they pose risks such as impaired circulation, skin breakdown, and decreased mobility.

B. Soft heel protectors help prevent pressure injuries and provide cushioning for clients at risk of skin breakdown. They are a non-restrictive intervention and do not require verification with the provider.

C. An abduction pillow helps maintain proper hip alignment and prevents dislocation in clients following hip surgery. This is a standard postoperative intervention that does not require additional verification.

D. Mitten restraints are a less restrictive alternative to wrist restraints and may be used to prevent a client from interfering with medical devices. However, their use still requires a provider's order and close monitoring to ensure patient safety.

• Infection: Poor glycemic control, indicated by an elevated hemoglobin A1c of 9.5%, leads to impaired immune function, delayed wound healing, and increased risk of postoperative infections. Chronic hyperglycemia promotes bacterial growth, reduces leukocyte function, and compromises vascular integrity, further predisposing the client to infections.
• Deep vein thrombosis (DVT): Postoperative immobility, increased coagulation, and endothelial injury increase DVT risk. However, BUN of 15 mg/dL is within the normal range and does not indicate dehydration or hemoconcentration, which would contribute to thrombus formation.
• Hypovolemia: Reduced blood volume typically presents with signs such as hypotension, tachycardia, and elevated BUN/creatinine ratio. Preoperative hypertension does not indicate hypovolemia and is more commonly associated with chronic vascular resistance rather than acute fluid loss.
• BUN of 15 mg/dL: A BUN level within the normal range does not suggest an increased risk for DVT or fluid imbalance. It primarily reflects renal function and hydration status, neither of which are significantly altered in this case.
• Preoperative hypertension: While chronic hypertension is a cardiovascular risk factor, it does not indicate hypovolemia, which would present with dehydration-related signs such as orthostatic hypotension, tachycardia, and decreased urine output.
• Hemoglobin A1c: A value of 9.5% indicates poor long-term glycemic control, which impairs immune function and slows wound healing. Elevated glucose levels reduce neutrophil function, impair macrophage activity, and increase oxidative stress, all of which contribute to a heightened infection risk.