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 B
Explanation
Choice A rationale
The right supervision is one of the five rights of delegation, but it is not the correct answer for this question. The right supervision ensures that the delegated task is performed correctly and safely, with appropriate oversight and support from the delegating nurse.
Choice B rationale
The right person is correct. The right person ensures that the task is delegated to a qualified and competent individual who has the necessary education, training, and experience to perform the task safely and effectively.
Choice C rationale
The right task is one of the five rights of delegation, but it is not the correct answer for this question. The right task ensures that the task being delegated is appropriate for the patient’s condition and within the scope of practice for the person to whom it is being delegated.
Choice D rationale
The right circumstances is one of the five rights of delegation, but it is not the correct answer for this question. The right circumstances ensure that the task is delegated in an appropriate setting and situation, considering the patient’s condition and the availability of resources.
Correct Answer is C
Explanation
Choice A rationale
This statement does not provide a recommendation for the next steps in the patient’s care. The R step in SBAR stands for Recommendation, which involves suggesting what should be done to address the situation. Stating that there are no provider’s prescriptions available does not fulfill this requirement.
Choice B rationale
This statement is more appropriate for the Assessment step, where the nurse describes the patient’s current condition. The R step should focus on what actions need to be taken next, not just the patient’s current state.
Choice C rationale
This statement is correct because it provides a clear recommendation for the next steps in the patient’s care. The R step in SBAR is meant to suggest what should be done to address the situation, and reviewing the client’s orders is a specific action that can be taken.
Choice D rationale
This statement is more appropriate for the Situation or Background steps, where the nurse describes what has happened to the patient. The R step should focus on what actions need to be taken next, not just the patient’s history.
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