A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

A. Verify the client's name on their identification bracelet with the medication administration record: While confirming the client’s identity is a critical safety step before administering medications, this action is part of the “five rights” of medication administration rather than the medication reconciliation process.

B. Call the pharmacy to determine whether the client's medications are available: Contacting the pharmacy may be necessary for obtaining or refilling prescriptions, but it is not part of the reconciliation process. Medication reconciliation focuses on comparing existing medications with new orders to prevent omissions, duplications, or interactions.

C. Compare the client's home medications with the provider's prescriptions: This is the primary purpose of medication reconciliation. The nurse reviews the client’s current medications, including prescription, over-the-counter, and herbal supplements, and compares them with new provider orders to identify discrepancies, prevent medication errors, and ensure continuity of care.

D. Place the client's home medication bottles in a secure location: Safely storing the client’s home medications is important for preventing misuse or errors, but it is a supportive action rather than part of the reconciliation process. The critical step is analyzing and reconciling the medications to ensure safe and accurate therapy.

Rationale for correct choices

• Review medications that might be causing confusion: Before initiating restraints, the nurse should first assess for reversible causes of the client’s confusion. Certain medications, especially sedatives or antiemetics, can contribute to altered mental status in acutely ill clients. Identifying medication-related causes allows the healthcare team to adjust therapy and potentially resolve the confusion without restrictive measures.

• Using other methods to keep the client safe: Restraints are considered a last resort and should only be used after less restrictive interventions have been attempted. Alternative safety measures include frequent reorientation, close observation, moving the client closer to the nurses’ station, or using bed alarms. These interventions promote safety while preserving the client’s dignity and autonomy.

Rationale for incorrect choices

• Obtain a prescription from the provider for restraints: A provider’s prescription is required for restraints, but it should only be requested after other safety interventions have failed. The nurse must first assess contributing factors and attempt less restrictive methods. Jumping immediately to restraints can increase agitation, risk injury, and violate restraint guidelines.

• Assess where the restraints will be placed on the client: Assessment of placement sites is necessary if restraints are eventually applied to prevent skin injury or impaired circulation. However, this step occurs only after the decision to use restraints has been made. Prioritizing this assessment before attempting alternatives would bypass less restrictive safety measures.

• Padding bony prominences under the restraint: Padding protects skin integrity when restraints are in use, but this intervention occurs during restraint application. Since restraints are not yet indicated, padding is not an immediate priority. The nurse must first attempt other safety strategies to prevent harm. Protective padding becomes relevant only if restraints are required.

• Monitoring the client in restraints every 2 hrs: Frequent monitoring is required for clients who are already in restraints to assess circulation, skin condition, and continued need for restraint use. In this scenario, restraints have not been applied. Monitoring requirements apply after restraints are initiated, not before the decision to use them is made.