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 B

Explanation

A. Furosemide is a loop diuretic that typically causes potassium loss, so an increase in potassium levels would not be expected as an indication of effectiveness.
B. Furosemide is prescribed to reduce fluid volume overload, which often manifests as peripheral edema in patients with heart failure. A decrease in peripheral edema indicates that the medication is effectively reducing fluid retention.
C. Furosemide is not typically prescribed to decrease cardiac output but rather to reduce fluid volume overload, which may help improve cardiac function indirectly.
D. Furosemide is not typically prescribed to increase venous pressure but rather to decrease fluid volume overload, which may help reduce venous pressure over time.

A. Offer sips of water 4 hr following surgery. B. Assist the adolescent to ambulate 12 hr following surgery. C. Maintain the head of the bed at a 30° angle. D. Ensure two nurses logroll the adolescent every 2 hr.

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.

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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 assessing a school-age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is B

Explanation

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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