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: Placing a mask on the client is unnecessary unless the rash is associated with a respiratory pathogen, which is unlikely for an abdominal rash. PPE, like gloves, is critical to protect the nurse from potential infectious causes, such as herpes zoster, ensuring safety during direct assessment of the rash.

Choice B reason: Determining if pain preceded cream application helps identify the rash’s cause but is not the first priority. Using PPE during assessment protects the nurse from infectious rashes, like herpes zoster, which is suggested by the painful, unilateral distribution. Safety during direct contact takes precedence over historical data collection.

Choice C reason: Questioning exposure to sick children may identify infectious causes like varicella but is secondary to nurse safety. A painful abdominal rash suggests herpes zoster, requiring PPE during assessment. Protecting the nurse from potential pathogens during physical examination is the immediate priority before gathering exposure history.

Choice D reason: Using PPE, such as gloves, is critical when assessing a painful abdominal rash, which may indicate herpes zoster, a contagious infection. PPE prevents nurse exposure to infectious agents during direct contact. This action ensures safety, aligning with infection control protocols, especially for unilateral, painful rashes suggestive of shingles.

Choice A reason: Comparing health status with defining criteria helps diagnose problems but is less relevant when setting goals. Goal identification focuses on addressing established nursing problems to achieve measurable outcomes. This action is part of assessment, not the primary step in formulating care plan goals, which requires prioritizing existing issues.

Choice B reason: Reviewing priority nursing problems ensures goals align with the client’s most urgent needs. This step clarifies the focus of care, enabling the nurse to set specific, measurable, and patient-centered goals. It integrates assessment data and nursing diagnoses, forming the foundation for effective care planning, as per nursing process standards.

Choice C reason: Listing immediate nursing actions focuses on interventions, not goal-setting. Goals define desired outcomes, while actions are strategies to achieve them. This approach skips the critical step of establishing priorities and outcomes, risking a fragmented care plan that may not address the client’s holistic needs effectively.

Choice D reason: Ensuring all prescribed treatments are initiated addresses physician orders but not nursing-specific goals. Nursing goals focus on patient outcomes based on nursing diagnoses, not just medical treatments. This action is relevant to implementation, not the primary step in identifying care plan goals, which requires nursing judgment.