A nurse is discussing the mechanism of action of antibiotics with a patient. Which of the following statements best demonstrates a nurse's understanding of this concept?

A. Secure the restraints to the lowest bar of the side rail: Restraints should never be tied to the side rails, as this can cause injury if the client attempts to move. They should be secured to a stable part of the bed frame that moves with the client, ensuring safety and preventing harm.

B. Secure the restraints using a quick-release tie: Quick-release knots allow the nurse to remove restraints rapidly in an emergency, such as sudden respiratory distress or circulatory compromise. This method balances safety with the ability to intervene immediately if needed.

C. Anticipate removing the restraints every 4 hr.: Restraints should be removed or assessed more frequently, typically every 2 hours for adults, to check circulation, skin integrity, and range of motion. Waiting 4 hours can increase the risk of injury or skin breakdown.

D. Ensure four fingers fit under the restraints to prevent constriction: Only enough space for two fingers should be placed between the restraint and the client’s skin. Four fingers would make the restraint too loose, increasing the risk of slipping and reducing effectiveness in preventing harm.

Rationale for correct choices:

• Deep vein thrombosis: The client’s limited mobility, recent hip fracture, and unilateral calf swelling and warmth significantly increase the risk for DVT. Immobility reduces venous return, promoting clot formation in the lower extremities, making early assessment and preventive measures critical.
• Pulmonary embolism: A DVT can dislodge and travel to the lungs, causing a potentially life-threatening pulmonary embolism. Monitoring for signs such as sudden shortness of breath, chest pain, or hypoxia is essential to prevent serious complications.

Rationale for incorrect choices:

• Diarrhea: There is no evidence of gastrointestinal upset, increased bowel movements, or infection that would place the client at risk for diarrhea.
• Hypertension: The client’s vitals do not indicate elevated blood pressure, and there are no factors in the scenario suggesting risk for acute hypertension.
• Hypocalcemia: The client’s lab results do not indicate low calcium levels, and there are no signs or symptoms suggestive of hypocalcemia, making this an unlikely risk.