A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

A. “I should assess the client's skin integrity every 8 hours while in mechanical restraints.”: Skin integrity should be assessed much more frequently, typically every 1 to 2 hours, to prevent pressure injuries and ensure circulation is not impaired.
B. “I should expect the provider to evaluate the client within 4 hours of restraint application.”: Provider evaluation is required sooner, generally within 1 hour of restraint application, to ensure the necessity and appropriateness of restraints.
C. “I should ask the provider to write a prescription for mechanical restraints as needed.”: Restraints require a specific, time-limited provider order; PRN (as needed) orders are not appropriate because continuous assessment is necessary to determine ongoing need.
D. “I should visually monitor the client continuously when in mechanical restraints.”: Continuous visual monitoring is essential to ensure the client’s safety, prevent injury, and assess for any distress while restraints are in place.

A. Wear a dosimeter film badge to measure exposure: The dosimeter badge tracks cumulative radiation exposure to ensure the nurse stays within safe limits. It is essential personal protective equipment when caring for clients undergoing internal radiation therapy.
B. Place a caution sign on the client’s door: A radiation warning sign alerts staff and visitors about the presence of a radioactive source, ensuring they follow safety protocols to minimize unnecessary exposure.
C. Discard bed linens from the client's room at the end of each day: Linens are not contaminated by a sealed implant, as the radiation source is enclosed and does not leak into the environment. Linens should be handled per routine procedure unless visibly soiled.
D. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should be instructed to stay at least 6 feet (approximately 183 cm) away and limit visits to 30 minutes. The 2-foot distance is insufficient to ensure safety from radiation exposure.
E. Don a lead apron when providing care: A lead apron helps shield the nurse from radiation exposure when close contact is necessary. It is a standard precaution when interacting with clients who have a sealed radiation source.