A nurse is caring for a client who had an open cholecystectomy 24 hours ago.

The client’s vital signs have been stable over the last 24 hours, with the most recent temperature

98.6° F(37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and pulse 78/min, but are now changing.

Which set of vital signs indicates that the nurse should contact the health care provider?

This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.

Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.

The client may or may not need to use the bedpan depending on their fluid intake and output.

Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.

The client may or may not need to vomit depending on their underlying condition.

Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.