A prescription for bilateral soft wrist restraints is obtained for an older adult client who has repeatedly removed the nasogastric tube (NGT) and IV sites. After applying the restraints, which action is most important for the nurse to take?

Choice A reason: The rebound phenomenon, related to cerebellar function, is irrelevant to heating pad application. Heat therapy requires assessing skin sensation to prevent burns. Neurosensory impairment increases burn risk, making sensory assessment critical. Checking for rebound phenomenon does not address the immediate safety concerns of heat application.

Choice B reason: Muscle strength and tone inform mobility or rehabilitation but are not primary concerns for heating pad use. Impaired sensation heightens burn risk, as clients may not feel excessive heat. Sensory assessment takes precedence to ensure safe application, as muscle status does not directly impact heat therapy safety.

Choice C reason: Limitations to range of motion are relevant for mobility but not critical for heating pad safety. Neurosensory impairment increases the risk of burns, as clients may not detect overheating. Sensory assessment ensures the client can report discomfort, making it the priority over joint mobility before applying heat.

Choice D reason: Assessing neurosensory impairment is critical before applying a heating pad, as impaired sensation increases burn risk. Clients with neuropathy or reduced sensation may not feel excessive heat, leading to tissue damage. This assessment ensures safe application, aligning with nursing safety protocols to prevent thermal injury during heat therapy.

Choice A reason: High Fowler’s position aids breathing in respiratory distress but is not universally indicated without context. It may strain the client’s back or increase fatigue if sustained. Keeping mucous membranes moist is a broader intervention, preventing complications like oral infections or discomfort, especially in dehydrated or oxygen-dependent clients, making it more appropriate.

Choice B reason: Reporting changes in urine color monitors renal or hydration status but is less immediate than maintaining mucous membranes. Dry membranes risk infection or discomfort, particularly in clients on oxygen or with reduced oral intake. Urine monitoring is secondary, as it reflects longer-term changes rather than addressing an urgent physiological need.

Choice C reason: Keeping mucous membranes moist prevents drying, which can lead to infections, discomfort, or impaired swallowing. This is critical for clients on oxygen, with reduced intake, or in dry environments. Moist membranes support airway protection and comfort, aligning with nursing priorities to maintain basic physiological functions and prevent complications.

Choice D reason: Recording daily weight tracks fluid status or nutritional changes but is less urgent than moist mucous membranes. Dry membranes pose immediate risks like infection or airway irritation, especially in vulnerable clients. Weight monitoring is a longitudinal assessment, secondary to addressing acute comfort and infection prevention needs.