The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

The correct answer is c. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. This intervention ensures the client’s safety and provides familiar support, which can help reorient and calm the client.

Choice A reason: Administering a prescribed narcotic antagonist assumes the agitation is due to narcotic accumulation without evidence. This could lead to unnecessary medication administration.

Choice B reason: Requesting restraints should be a last resort due to the risks of injury and increased agitation. Restraints can also lead to further complications.

Choice C reason: Raising the side rails and involving the family provides immediate safety and emotional support, which can help reorient the client. Familiar faces can be very calming and reassuring.

Choice D reason: Instructing a UAP to check on the client every 15 minutes lacks the immediate family support that can help reorient the client. Continuous monitoring is important, but family involvement is more effective.

- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.

- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.

- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.

Therefore, option C is the correct answer, while options A, B, and D are incorrect.

Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.

Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.

Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in the technique.