A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes?

A. Choose the most restrictive type of restraint that will fit the client: Restraint use follows the principle of least restriction. The least restrictive device that ensures safety should always be selected to preserve client autonomy and reduce complications such as agitation, decreased circulation, or psychological distress. Choosing the most restrictive option increases the risk of harm and violates best practice guidelines.

B. Assess skin integrity under the restraint once per day: Clients in restraints require frequent monitoring, including assessment of skin integrity, circulation, and neurovascular status at least every 2 hours or according to facility policy. Assessing only once per day is insufficient and increases the risk of pressure injuries, impaired circulation, and nerve damage.

C. Attach the restraint securely to the side rail when the client is in bed: Restraints should be secured to the bed frame, not the side rails. Side rails move when raised or lowered, which can cause injury or accidental tightening of the restraint. Securing to the immovable bed frame ensures consistent positioning and reduces injury risk.

D. Secure the restraint with an easy-to-release tie: Restraints should be secured using a quick-release knot or buckle that allows rapid removal in case of emergency. This method ensures client safety by permitting immediate release during situations such as respiratory distress or fire, while still maintaining appropriate security during use.

A. Schedule the medication at meal times: Administering the medication with meals may improve tolerance for some drugs, but it does not address the ethical and legal issue of the client’s right to refuse. The nurse cannot override the client’s autonomy by adjusting timing without consent.

B. Request the family talk to the provider about administering the medication by injection: Changing the route of administration without the client’s informed consent raises ethical and legal concerns. Injectable administration may be appropriate only if the client consents or if there is a court order for involuntary treatment under specific circumstances.

C. Inform the family that the client has the right not to take the medication: Clients with decision-making capacity have the right to refuse treatment, including psychotropic medications. The nurse should educate the family about respecting the client’s autonomy while ensuring the client is informed about potential consequences of refusing treatment.

D. Ask the family what foods the client likes: While considering food preferences may support medication adherence in willing clients, it is inappropriate to use food to covertly administer medication. This practice violates informed consent and ethical principles and can undermine trust between the client, family, and healthcare team.