A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

A) “I should expect the provider to evaluate the client within 4 hours of restraint application.”:The provider must evaluate the client within a shorter timeframe, typically within 1 hour of applying mechanical restraints, to ensure the client’s safety and appropriateness of the intervention.

B) “I should visually monitor the client continuously when in mechanical restraints.”:Continuous visual monitoring is essential to ensure the client’s safety and well-being while in mechanical restraints. This allows for immediate intervention if any complications or distress arise.

C) “I should assess the client’s skin integrity every 8 hours while in mechanical restraints.”:Skin integrity should be assessed more frequently, typically every 2 hours, to prevent skin breakdown and other complications associated with prolonged use of restraints.

D) “I should ask the provider to write a prescription for mechanical restraints as needed.”:Mechanical restraints should not be used on an as-needed basis. They require a specific, time-limited order from a provider, and their use must be justified and documented according to strict guidelines and protocols.

A. "Limit your child's potassium intake while she is taking this medication.": This statement is incorrect. In fact, potassium intake should generally be adequate because digoxin can lead to increased potassium loss, and low potassium levels can increase the risk of digoxin toxicity.

B. “Repeat the dose if your child vomits within 1 hour after taking the medication.": This statement is not recommended. The nurse should advise parents to contact their healthcare provider for guidance on whether to administer a repeat dose after vomiting, as it depends on the individual situation and timing.

C. "Have your child drink a small glass of water after swallowing the medication.": This statement is appropriate as it can help ensure that the medication is swallowed properly and aids in its absorption. Adequate hydration is important for all medications.

D. "You can add the medication to a half-cup of your child's favorite juice.": This is not advisable because mixing digoxin with juice can alter the absorption of the medication. It's generally better to administer it alone to ensure proper dosing and effectiveness.