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?
Secure the restraints with a quick-release knot.
Assess the child every 4 hr while in restraints.
Tie the restraints to the side rails of the child's bed.
Request that the provider renew the prescription for restraints every 48 hr.
The Correct Answer is A
A. Secure the restraints with a quick-release knot: Using a quick-release knot ensures that restraints can be removed quickly in an emergency, such as if the child experiences respiratory distress or circulatory compromise. This practice promotes safety while maintaining control of aggressive behavior.
B. Assess the child every 4 hr while in restraints: Restraints require frequent monitoring, typically every 15–30 minutes for a child, to assess circulation, skin integrity, and psychological status. Assessing only every 4 hours would place the child at risk for injury or complications.
C. Tie the restraints to the side rails of the child's bed: Restraints should never be tied to side rails, as this can increase the risk of injury if the bed is adjusted or the child struggles. Restraints should be secured to a stable part of the bed frame that does not move.
D. Request that the provider renew the prescription for restraints every 48 hr: Pediatric restraint prescriptions are typically valid for a much shorter period, often 1–2 hours depending on hospital policy, and require frequent reassessment. A 48-hour renewal is unsafe and does not comply with standard guidelines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will take my child's pulse for 30 seconds before giving the medication.": Checking the pulse for 1 full minute is crucial before administering digoxin, especially in preschool-age children, because the medication can slow the heart rate. If the pulse is below the prescribed threshold (usually <90–100 bpm in young children), the dose should be held.
B. "I will mix the medication in a glass with 4 ounces of orange juice.": Digoxin can be given with a small amount of liquid, but large volumes of juice are not recommended because excessive liquid may make it difficult for the child to take the full dose. Also, certain juices may interact with absorption; using a small amount of water or juice is safer.
C. "I will repeat the dose if she vomits after taking the medication.": Repeating a dose after vomiting is unsafe because it can result in digoxin toxicity, especially in young children. The parent should contact the healthcare provider for guidance instead of administering a second dose.
D. "I will tell my child to brush her teeth after she takes this medication.": Digoxin elixir is prepared in a high-sugar syrup base to make it more palatable for children. Frequent administration of this sticky, sugary liquid can lead to tooth decay and dental carries. Brushing the teeth (or rinsing the mouth in younger infants) after each dose is an essential measure.
Correct Answer is B
Explanation
A. Mottled skin: Mottled or dusky skin is more commonly associated with poor perfusion and severe dehydration or shock. Moderate dehydration typically presents with delayed capillary refill and dry mucous membranes rather than significant skin color changes.
B. Capillary refill 3 seconds: A capillary refill time of about 3 seconds is consistent with moderate dehydration in infants. This finding reflects decreased circulating volume and peripheral perfusion, which commonly occurs with fluid losses from diarrhea.
C. Bulging anterior fontanel: A bulging fontanel is associated with increased intracranial pressure or fluid overload. Dehydration more commonly causes a sunken fontanel due to decreased fluid volume.
D. Decreased respiratory rate: Respiratory rate is not typically decreased in moderate dehydration. Infants may have normal or increased respiratory rates as a compensatory response to metabolic acidosis from fluid and electrolyte losses.
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