A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?

Tie the restraints to the side rails of the child's bed.

Request that the provider renew the prescription for restraints every 48 hr.

Secure the restraints with a quick-release knot.

Assess the child every 4 hr while in restraints.

Answer and Explanation

The Correct Answer is C

A.   Tying restraints to the side rails poses a risk of injury to the child and is not a recommended practice.
B.   Renewing the prescription for restraints every 48 hours is important, but it does not directly address the proper application of restraints.
C.   Securing restraints with a quick-release knot allows for quick removal in case of emergency and is the correct method for applying restraints.
D.   Assessing the child every 4 hours while in restraints is important, but it does not address the proper application of restraints.

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Correct Answer is D

Explanation

A. Offering sips of water 4 hours following surgery may be too early and could increase the risk of aspiration in the immediate postoperative period.
B. Ambulation 12 hours following surgery may not be appropriate depending on the extent of the surgery and the patient's condition. It's important to follow physician orders regarding activity and mobilization.
C. Maintaining the head of the bed at a 30° angle may help prevent respiratory complications but is not specific to scoliosis repair with spinal instrumentation.
D. Logrolling the adolescent every 2 hours helps to prevent complications such as pressure ulcers and maintains proper alignment of the spine postoperatively.

A. Discard the first voided specimen. B. Void every hour. C. Cleanse the perineum with a povidone-iodine solution prior to voiding. D. Save the final specimen in a separate container.

Correct Answer is A

Explanation

A. Discarding the first voided specimen is necessary to ensure accuracy in a 24-hour urine collection. This helps eliminate any urine that has been in the bladder prior to the start of the collection period.
B. Voiding every hour is not necessary for a 24-hour urine collection. The goal is to collect all urine produced over a 24-hour period, not voiding at set intervals.
C. Cleansing the perineum with a povidone-iodine solution prior to voiding is not typically necessary for a 24-hour urine collection unless specifically instructed by the healthcare provider.
D. Saving the final specimen in a separate container is not necessary for a 24-hour urine collection. All urine produced during the specified collection period should be saved in the same container.

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A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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