A nurse assesses a patient with restraints. The nurse should:
Loosen the restraints and assess the patient’s skin.
Document the findings in the patient’s chart.
Continue to monitor the patient without making any changes.
Apply ice packs to reduce swelling.
The Correct Answer is B
Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A 30-year-old male patient with an active GI bleed requiring multiple blood transfusions is not suitable for assignment to an LPN. This patient is unstable and requires close monitoring and frequent assessments, which are beyond the LPN’s scope of practice. The RN should manage this patient to ensure proper care and timely interventions.
Choice B rationale
A 55-year-old male patient who is post-surgery and ready for discharge, requiring discharge instructions, is also not suitable for assignment to an LPN. Discharge instructions involve comprehensive education and assessment of the patient’s understanding, which are responsibilities of the RN. The RN must ensure the patient comprehends the instructions and can safely manage their care at home.
Choice C rationale
A 40-year-old diabetic patient requiring re-teaching on insulin administration is the best choice for assignment to an LPN. This patient is stable and the task of re-teaching insulin administration falls within the LPN’s scope of practice. The LPN can effectively provide education and ensure the patient understands how to administer insulin correctly.
Choice D rationale
A newly admitted patient is not suitable for assignment to an LPN. New admissions require comprehensive assessments and care planning, which are responsibilities of the RN. The RN must evaluate the patient’s condition, develop a care plan, and initiate appropriate interventions.
Correct Answer is A
Explanation
Choice A rationale
Providing information is the communication technique used by the nurse in this scenario. The nurse is giving the patient information about the benefits of taking pain medication before physical therapy, which helps the patient understand and manage their pain effectively.
Choice B rationale
Confrontation involves addressing discrepancies or conflicts directly, which is not what the nurse is doing in this scenario. The nurse is providing information, not confronting the patient.
Choice C rationale
Summarizing involves restating the main points of a conversation to ensure understanding. While the nurse is providing information, they are not summarizing the conversation.
Choice D rationale
Probing involves asking questions to gain more information. The nurse is not asking questions in this scenario but is providing information to the patient.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.