The nurse cares for a client in 2-point soft wrist restraints to prevent them from pulling out their endotracheal tube. What action(s) should the nurse include in the client's care to prevent complications?

A. An adolescent client with diabetes mellitus who is admitted for hyperglycemia: Diabetes can impair circulation and wound healing, but adolescents are generally mobile and able to reposition independently. Short-term hyperglycemia alone does not create sustained pressure over bony prominences. Mobility significantly reduces pressure injury risk.

B. A middle-aged adult client who is comatose following a stroke: Coma results in complete immobility, loss of protective reflexes, and inability to reposition or perceive discomfort. Prolonged pressure over bony areas compromises tissue perfusion and increases ischemic injury. Neurologic impairment and immobility place this client at the highest risk.

C. An older adult client who is recovering from a sinus infection: Advanced age can increase vulnerability to skin breakdown, but a sinus infection does not typically limit mobility or sensation. Clients who are alert and ambulatory can relieve pressure independently. Risk remains relatively low without immobility.

D. An adult client with a spinal cord injury who engages in daily physical therapy: Although spinal cord injury increases baseline risk due to sensory deficits, regular physical therapy promotes mobility, circulation, and pressure relief. Active repositioning and therapeutic movement reduce prolonged pressure exposure. Consistent mobility lowers overall risk.

A. Obtain the client's apical heart rate: A radial pulse of 52 beats/minute is below the normal adult range (60–100 bpm), indicating bradycardia. Assessing the apical heart rate provides a more accurate measure of cardiac output and identifies potential discrepancies between central and peripheral pulses. This step is the immediate priority before further interventions.

B. Assess for a pulse deficit: Pulse deficit measurement compares apical and radial pulses to identify ineffective contractions, often in atrial fibrillation. This assessment is secondary and requires the apical pulse first.

C. Notify the healthcare provider: While notification may be necessary depending on findings, the nurse must first verify the heart rate and assess the client’s condition before contacting the provider. Immediate confirmation guides appropriate communication.

D. Review previous vital sign trends: Reviewing trends is useful to determine if bradycardia is new or chronic, but it does not replace the immediate need to accurately assess the current cardiac status. Immediate verification takes priority.