A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?
Explanation & Rationale
A. Apply mitten restraints to prevent the client from disconnecting their tube feeding: Mitten restraints are often used to prevent clients from pulling out tubes or disrupting medical devices. The nurse can apply these restraints as long as they follow the prescribed protocol. B. Apply soft heel protectors bilaterally while client is in bed: Soft heel protectors are commonly used to prevent pressure ulcers or skin breakdown in immobile clients. This is a standard, non-controversial intervention and does not require verification. C. Applying a vest restraint daily at bedtime to prevent nighttime wandering is considered a physical restraint used for convenience or punishment, which is a violation of client rights and safety. Restraints should only be used as a last resort when all less restrictive alternatives have failed and for the shortest duration possible. D. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation: The use of an abduction pillow is common after hip replacement surgery or for patients at risk of hip dislocation. This is an appropriate intervention.