A nurse on a postpartum unit is caring for a client.

Exhibits

For each finding, click to specify if the finding is consistent with uterine atony or infection. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row. (Note: Each column must have at least 1 response option selected)

Rationale:

A. I should visually monitor the client continuously when in mechanical restraints: Continuous visual monitoring is required when a client is placed in mechanical restraints to ensure safety, assess physical and psychological well-being, and promptly address any complications such as impaired circulation or distress.

B. I should ask the provider to write a prescription for mechanical restraints as needed: PRN (as needed) prescriptions for restraints are not permitted. A new, time-limited order must be obtained for each specific episode to ensure proper use and prevent misuse or overuse of restraints.

C. I should expect the provider to evaluate the client within 4 hours of restraint application: For adult clients, the provider must evaluate the client face-to-face within 1 hour of applying restraints, not 4 hours. This rule ensures timely review of the necessity and appropriateness of the intervention.

D. I should assess the client's skin integrity every 8 hours while in mechanical restraints: Skin integrity should be assessed at least every 2 hours or more frequently depending on facility policy. Waiting 8 hours increases the risk of skin breakdown and other complications.

Rationale:

A. Nitroglycerin transdermal patch: This prescription is incomplete because it lacks a dosage strength, application site, frequency, and duration. Without these details, safe administration cannot be ensured.

B. Aspirin 1 tablet daily: The prescription is incomplete as it does not specify the tablet’s strength (e.g., 81 mg or 325 mg). "1 tablet" is ambiguous and can vary based on available formulations.

C. Metoprolol 5 mg IV now: This is a complete prescription it includes the medication name, dose (5 mg), route (IV), and timing ("now"). It gives the nurse all essential information to safely administer the drug.

D. Furosemide 20 mg BID: While the medication, dosage, and frequency are provided, the route is missing. Furosemide can be given orally or intravenously, so this omission makes the prescription incomplete.