Which needle gauge should a nurse select when administering a medication subcutaneously?

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.