Which nursing intervention should be performed before applying client restraints?

This is essential because drainage from a large abdominal wound may collect under the client and be missed if only the dressing is inspected. The amount, color, and consistency of drainage should be documented and reported to the health care provider.

Choice A is wrong because feeling the top of the client’s legs will not help assess for drainage in a large abdominal wound.

Choice C is wrong because asking the client to cough forcefully may increase the risk of dehiscence (separation of wound edges) or evisceration (protrusion of internal organs through the wound) in a large abdominal wound.

Choice D is wrong because having the client sit up and lean forward may also increase the risk of dehiscence or evisceration in a large abdominal wound.

Normal ranges for wound drainage depend on the type, location, and size of the wound, as well as the stage of healing. Generally, drainage should decrease over time and change from bloody to serous.

“I feel uncomfortable praying with you, but I will find someone who won’t feel that way.” This statement by the nurse would best meet the client’s spiritual needs because it acknowledges the nurse’s own boundaries and feelings while also respecting the client’s request and finding a way to fulfill it.

Some possible explanations for why the other choices are wrong are:

Choice A is wrong because it does not address the client’s request to pray together and it assumes that the client wants a Bible without asking.

Choice B is wrong because it implies that the nurse does not want to pray with the client and that the client’s visitors would be more suitable for this task, which could make the client feel rejected or unsupported.

Choice C is wrong because it directly rejects the client’s request and discloses the nurse’s personal beliefs, which could create a sense of disconnection or conflict between the nurse and the client.