A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?
Plan to monitor the client every 30 min while restrained.
Request a provider to evaluate the client in person every 36 hr.
Ensure that the prescription for restraints be renewed every 6 hr.
Document the client's behavior every 15 min.
The Correct Answer is D
A. Monitoring every 30 minutes is insufficient; it should be more frequent.
B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.
C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.
D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Disconnecting the suction to the OG tube while holding the baby is not advisable, especially if the baby is on suction due to abdominal concerns such as NEC. The OG tube is used to decompress the stomach, and disconnecting it without proper instructions can worsen the condition. Therefore, this statement indicates a lack of understanding.
B: While genetic factors may influence some neonatal conditions, NEC is not a genetic disorder. The statement about passing a gene to the baby and potentially to the next child is not accurate in this context.
C: Necrotizing enterocolitis (NEC) is a severe gastrointestinal emergency commonly seen in preterm neonates, and it can lead to bowel perforation. In cases of extensive bowel damage or perforation, surgical intervention may be required, including the possibility of an ostomy. This is a correct statement that reflects the understanding of the potential treatment plan for the neonate.
D: NEC typically involves the inability to tolerate feedings, and in such cases, feeding is often withheld temporarily. The baby would not need high-calorie formula in this situation; instead, the focus would be on managing NEC, potentially with IV nutrition or parenteral nutrition (TPN), and addressing the need for surgical intervention.
Correct Answer is B
Explanation
A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Incorrect. Assessing medication use is a nursing responsibility and cannot be delegated to an AP.
B. Determine if the AP has the skills to perform the test: The nurse must ensure that the AP is competent to perform the task safely and accurately before delegation, as part of the nurse's responsibility in delegation.
C. Help the AP perform the blood glucose test: Incorrect. The task should be performed independently by the AP if delegated.
D. Have the AP check the medical record for prior blood glucose test results: Incorrect. Reviewing the medical record is a nursing responsibility and not typically delegated to an AP.
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