A nurse in an emergency department is caring for a client.
Complete the following sentence by using the list of options.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct choices
• Review medications that might be causing confusion: Before initiating restraints, the nurse should first assess for reversible causes of the client’s confusion. Certain medications, especially sedatives or antiemetics, can contribute to altered mental status in acutely ill clients. Identifying medication-related causes allows the healthcare team to adjust therapy and potentially resolve the confusion without restrictive measures.
• Using other methods to keep the client safe: Restraints are considered a last resort and should only be used after less restrictive interventions have been attempted. Alternative safety measures include frequent reorientation, close observation, moving the client closer to the nurses’ station, or using bed alarms. These interventions promote safety while preserving the client’s dignity and autonomy.
Rationale for incorrect choices
• Obtain a prescription from the provider for restraints: A provider’s prescription is required for restraints, but it should only be requested after other safety interventions have failed. The nurse must first assess contributing factors and attempt less restrictive methods. Jumping immediately to restraints can increase agitation, risk injury, and violate restraint guidelines.
• Assess where the restraints will be placed on the client: Assessment of placement sites is necessary if restraints are eventually applied to prevent skin injury or impaired circulation. However, this step occurs only after the decision to use restraints has been made. Prioritizing this assessment before attempting alternatives would bypass less restrictive safety measures.
• Padding bony prominences under the restraint: Padding protects skin integrity when restraints are in use, but this intervention occurs during restraint application. Since restraints are not yet indicated, padding is not an immediate priority. The nurse must first attempt other safety strategies to prevent harm. Protective padding becomes relevant only if restraints are required.
• Monitoring the client in restraints every 2 hrs: Frequent monitoring is required for clients who are already in restraints to assess circulation, skin condition, and continued need for restraint use. In this scenario, restraints have not been applied. Monitoring requirements apply after restraints are initiated, not before the decision to use them is made.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Document the provider's statement in the medical record: Accurate documentation of the provider’s instructions and the client’s condition is important for legal and clinical communication purposes. Documentation alone does not address the immediate risk to the client. When a client is showing signs of hemorrhagic shock, prompt escalation is necessary.
B. Complete an incident report: Incident reports are used for internal quality improvement and risk management after an event has occurred or when a significant safety issue arises. Completing an incident report does not provide an immediate solution to the client’s unstable condition. The priority in this situation is advocating for the client and escalating concerns.
C. Consult the facility's risk manager: Risk managers are typically involved in analyzing adverse events, legal issues, or systemic safety concerns after the situation has been stabilized. Contacting the risk manager does not provide timely clinical intervention for a patient who may be actively deteriorating from hemorrhagic shock.
D. Notify the nursing manager: When a provider’s response does not adequately address a potentially life-threatening condition, the nurse should activate the chain of command. Hemorrhagic shock can rapidly lead to severe hypotension, organ hypoperfusion, and death if not treated promptly. Informing the nursing manager allows further escalation to ensure the client receives urgent evaluation and intervention.
Correct Answer is B
Explanation
A. Bend at the waist: Bending at the waist while lifting places excessive strain on the lumbar spine and increases the risk of back injury. Proper lifting technique requires bending at the knees and hips while keeping the back straight to distribute the weight more safely across the larger leg muscles.
B. Stand close to the cabinet when lifting it: Standing close to the object reduces leverage and minimizes the force on the lower back. Keeping the load near the body maintains balance, improves control, and decreases the risk of musculoskeletal injury, making this a key ergonomic principle for safe lifting.
C. Use the back muscles for lifting: Lifting primarily with the back muscles increases the risk of strain or injury to the lumbar region. Instead, the nurse should engage the strong muscles of the legs and gluteal region to perform the lift safely while keeping the back aligned.
D. Keep the feet close together: Keeping the feet close together reduces stability and balance while lifting. A proper stance requires feet shoulder-width apart to provide a broad base of support, allowing safe weight transfer and reducing the risk of falls or musculoskeletal injury.
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