A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first?

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) Hydrochlorothiazide: Hydrochlorothiazide is a thiazide diuretic that promotes sodium and water excretion, leading to decreased blood volume and decreased potassium excretion. While it can cause hypokalemia due to increased potassium excretion, it does not typically lead to hyperkalemia.

B) Spironolactone: Spironolactone is a potassium-sparing diuretic that inhibits aldosterone, leading to decreased sodium reabsorption and increased potassium retention. This mechanism of action can predispose clients to hyperkalemia due to potassium retention. Additionally, spironolactone can cause hyponatremia by promoting the excretion of sodium and water. Therefore, clients receiving spironolactone are at risk for both hyperkalemia and hyponatremia.

C) Furosemide: Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle, promoting sodium, chloride, potassium, and water excretion. While it can cause hypokalemia due to increased potassium excretion, it does not typically lead to hyperkalemia.

D) Metolazone: Metolazone is a thiazide-like diuretic that acts similarly to hydrochlorothiazide by promoting sodium and water excretion. Like hydrochlorothiazide, it can cause hypokalemia due to increased potassium excretion but does not typically lead to hyperkalemia.