A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?
Evaluate the need for the client to remain in mitten restraints.
Assist the client with range-of-motion exercises of the hands.
Instruct the client's family about the purpose of mitten restraints.
Determine the circulation status of the affected extremities every 2 hr
The Correct Answer is B
Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.
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Related Questions
Correct Answer is C
Explanation
c. New onset of hearing loss.
When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse effect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can affect hearing and balance¹.
Correct Answer is D
Explanation
After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.
Offering sips of clear fluids is not a priority at this time as the child may still be disoriented and at risk of choking. Placing the child in a supine position is also not recommended because the child may have difficulty breathing due to muscle weakness or constriction of the airways. Administering an oral antiepileptic medication is not appropriate at this time unless prescribed by a healthcare provider.
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