A nurse in a provider's office is reviewing data from a client's medical record.
Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Choice A rationale

Administering vaginal cream is a medication administration task requiring knowledge and skills within the licensed nurse's scope of practice. Assistive personnel (AP) are not authorized to perform this procedure due to the potential for complications and the need for clinical judgment.

Choice B rationale

Providing postmortem care is a task that AP can perform as it involves basic care activities, such as bathing and positioning, which do not require specialized nursing skills. This allows the nurse to focus on more complex patient needs.

Choice C rationale

Suctioning a tracheostomy is a procedure that requires clinical assessment and intervention skills. Due to the potential for complications, it is within the licensed nurse's scope of practice, not the AP's.

Choice D rationale

Changing a peripheral IV dressing involves assessment skills and requires sterile technique to prevent infection. This task is beyond the scope of practice for AP and should be performed by a licensed nurse.

Choice A rationale

Padding bony prominences helps prevent skin breakdown and pressure ulcers, which are critical considerations when using restraints to avoid additional complications for the client.

Choice B rationale

Tying restraints to the bed rail is unsafe because it can lead to injury if the bed rail is moved. Restraints should be tied to the bed frame to prevent accidental harm.

Choice C rationale

Using a square knot for restraints is inappropriate as it is difficult to untie quickly in an emergency. Quick-release knots are recommended for safety and efficiency.

Choice D rationale

Observing the client's skin integrity every 2 hours is essential to detect early signs of skin breakdown and take preventive actions to ensure the client's comfort and safety.

Choice E rationale

Ensuring that two fingers can fit between the restraint and the client ensures that the restraint is not too tight, allowing for circulation and reducing the risk of injury.