A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?

When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.

The correct answer is choicec. “You will need to wear a mask when outside of your room.”

Choice A rationale:

Visitors wearing protective gowns is important to prevent infection, but it is not the primary teaching point for the patient themselves.

Choice B rationale:

Patients undergoing allogeneic stem cell transplants are typically placed in private rooms to minimize the risk of infection, not semi-private rooms.

Choice C rationale:

Wearing a mask when outside the room is crucial for the patient to protect themselves from infections due to their compromised immune system during the transplant process.

Choice D rationale:

Negative-airflow rooms are used to prevent the spread of airborne infections from the patient to others, not necessarily to keep the air cleaner for the patient.