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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Asking for an order for an incentive spirometer is a recommendation, which belongs in the R step of SBAR. The B step should provide background information about the patient’s condition.
Choice B rationale
Providing the client’s history of sleep apnea is appropriate for the B step, which involves giving background information relevant to the current situation.
Choice C rationale
Describing the client’s current respirations and temperature is part of the Assessment step, not the Background step. The B step should focus on the patient’s medical history and relevant background information.
Choice D rationale
Stating that the client was found unconscious on the floor is part of the Situation step, not the Background step. The B step should provide background information about the patient’s condition.

A. The client properly uses a cane when ambulating and demonstrates a steady gait. B. The client takes a sleeping pill. C. The client uses a raised toilet seat. D. The client wears non-skid shoes.

Correct Answer is B

Explanation

Choice A rationale
The client properly using a cane and demonstrating a steady gait indicates that the client has good mobility and balance. This is not likely to contribute to falls. Proper use of assistive devices like canes can actually help prevent falls by providing additional support and stability.
Choice B rationale
The client takes a sleeping pill. Many sleeping pills, especially those in the benzodiazepine class, can cause drowsiness, dizziness, and impaired coordination, which significantly increase the risk of falls. These medications can affect the central nervous system, leading to decreased alertness and slower reaction times, making it more likely for the client to fall.
Choice C rationale
The client uses a raised toilet seat. Raised toilet seats are designed to make it easier for individuals to sit down and stand up from the toilet, reducing the risk of falls in the bathroom. This adaptation is generally considered a fall prevention measure rather than a risk factor.
Choice D rationale
The client wears non-skid shoes. Non-skid shoes are designed to provide better traction and reduce the likelihood of slipping. Wearing such shoes is a preventive measure against falls, not a contributing factor.

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A nurse assesses a patient with restraints. The nurse should:

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