A nurse is caring for a client who has been receiving warfarin and has an INR of 4.5. The client plans to leave the facility and refuses to wait until the provider can come and provide information about the result. Which action should the nurse take first?

Client transfer requires structured communication ensuring continuity of care through clinical status, functional assessment, care needs, and problem lists. Accurate handoff reduces errors, supports planning, and aligns interdisciplinary management across settings.

Rationale:

A. Including current self-care abilities and needs is essential to guide assistance levels in the receiving facility. It informs planning for activities of daily living. This supports functional assessment and ensures appropriate care planning upon transfer.

B. Describing the client’s current medical status provides a concise clinical overview necessary for safe continuity of care. It includes diagnoses, stability, and recent changes. This ensures accurate clinical handoff and promotes patient safety in the new setting.

C. Listing all medications received during hospitalization is unnecessary and excessive. Only current medications at transfer are relevant. Historical medication use may create confusion. This lacks clinical relevance and does not support efficient medication reconciliation.

D. Reviewing all physician orders throughout hospitalization is not required in a transfer report. Only active and relevant orders should be communicated. Including all orders is inefficient. This reduces communication clarity and adds unnecessary information overload.

E. Reporting both resolved and ongoing problems provides a clear clinical trajectory and highlights issues needing continued management. It ensures continuity and prevents recurrence of complications. This supports problem tracking and effective continuity of care.

Physical restraints are behavioral and safety interventions used in clients with severe agitation risk, impaired cognitive control, or danger to self/others. They require strict adherence to least restrictive measures, continuous circulatory monitoring, and frequent reassessment to prevent complications such as pressure injury, hypoxia, and psychological distress.

Rationale:

A. Clients in restraints must be placed in areas allowing continuous direct observation to prevent injury, entanglement, or circulatory compromise. This ensures rapid intervention if agitation or respiratory distress occurs. Supervision is a core safety requirement in restraint management protocols.

B. Restraints must be released at least every 2 hours to allow skin integrity assessment, range of motion, and elimination needs. This prevents neurovascular impairment, pressure injuries, and contractures. Scheduled release is a mandatory safety standard in restraint care.

C. Increasing stimulation with television may worsen sensory overload and agitation in restrained clients. This can escalate behavioral dysregulation rather than promote calming. It is not an appropriate intervention for restraint-associated anxiety management or behavioral control.

D. Soft, calming music reduces sympathetic nervous system activation and promotes relaxation in agitated clients. It supports de-escalation and decreases reliance on restraints. This is an appropriate non-pharmacologic intervention to reduce agitation and improve emotional regulation.

E. Covering tubes with gauze does not address underlying behavioral safety risk and may delay identification of complications such as dislodgement or obstruction. It is not a standard restraint alternative or safety intervention in clinical guidelines.

F. Encouraging family to leave reduces therapeutic support presence, which may worsen anxiety and agitation. Family involvement can provide reassurance and orientation. Removing support is not appropriate unless clinically indicated for safety reasons.

G. The need for continued restraints must be reassessed regularly to ensure least restrictive intervention is maintained. Ongoing evaluation prevents unnecessary restraint use and reduces risk of complications. This is a legal and ethical requirement in restraint management protocols.