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
Keeping the fluorescent ceiling light on at night can cause glare and disrupt sleep, which is not ideal for safety. It may also create shadows that can be disorienting.
Choice B rationale
Keeping the walker at the end of the bed is not practical. The walker should be within easy reach to ensure the client can use it immediately upon getting out of bed.
Choice C rationale
Placing grip bars in the shower is a correct and effective safety measure. Grip bars provide stability and support, reducing the risk of falls while bathing.
Choice D rationale
Placing an area rug at the entry of the bathroom can be a tripping hazard. Rugs can slip or bunch up, increasing the risk of falls.
Correct Answer is A
Explanation
Choice A rationale
Any competent adult regardless of age or health status can create an advance directive. Advance directives are legal documents that allow individuals to specify their preferences for medical care in case they become unable to communicate their wishes. Competence is the key requirement, meaning the individual must be able to understand and make decisions about their medical care.
Choice B rationale
Only individuals with terminal illnesses is incorrect. While individuals with terminal illnesses may benefit from having an advance directive, it is not a requirement. Advance directives are available to any competent adult, regardless of their health status.
Choice C rationale
Only individuals over the age of 65 is incorrect. Advance directives can be created by any competent adult, regardless of age. It is important for all adults to consider having an advance directive to ensure their medical preferences are known and respected.
Choice D rationale
Only individuals with chronic medical conditions is incorrect. While individuals with chronic medical conditions may benefit from having an advance directive, it is not a requirement.
Advance directives are available to any competent adult, regardless of their health status.
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