A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

The client reports that the restraints are too tight.

The client has been in the restraints for 4hr.

The client is able to calmly follow commands.

The client can explain the reasons for their behavior.

Answer and Explanation

The Correct Answer is C

A. The client reports that the restraints are too tight: This indicates a need for adjustment of the restraints but does not necessarily indicate that the restraints should be discontinued altogether. The client's ability to follow commands and behave safely is a more critical factor in deciding whether to discontinue the restraints.
B. The client has been in the restraints for 4 hours: While prolonged use of restraints should be avoided due to the risk of complications such as skin breakdown and loss of mobility, the duration alone may not be the sole indicator for discontinuing restraints. The client's behavior and ability to follow commands are more important considerations.
C. The client is able to calmly follow commands: This is the most appropriate finding indicating that the restraints should be discontinued. Calmly following commands suggests that the client's behavior has improved and they are no longer a danger to themselves or others, making the restraints unnecessary.
D. The client can explain the reasons for their behavior: While understanding the reasons for the client's behavior is important for addressing underlying issues, it does not necessarily indicate that the client is no longer a risk to themselves or others. The ability to calmly follow commands is a more immediate concern when deciding whether to discontinue restraints.

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Correct Answer is B

Explanation

Answer: B

Rationale:

A) Activate the fire alarm system:

While activating the fire alarm system is essential in alerting everyone to the fire, the immediate safety of the clients must be prioritized first. Ensuring clients are safe from potential harm should precede alerting others.

B) Evacuate clients from the area:

Evacuating clients from the area is the first priority as it directly ensures their safety. In the event of a fire, removing individuals from the source of danger is crucial to prevent injury or harm.

C) Obtain and use a fire extinguisher:

Using a fire extinguisher to put out the fire is important, but it should not be the first action. Ensuring clients are evacuated to safety must take precedence before attempting to control the fire.

D) Close the doors and windows on the unit:

Closing doors and windows can help contain the fire and smoke, but this should follow the evacuation of clients. The primary concern is to get clients to a safe area first before taking measures to contain the fire.

A. Changing the inner cannula on a tracheostomy B. Administering a platelet transfusion C. Irrigation of an external ear canal D. Inserting a tunneled central venous catheter

Correct Answer is D

Explanation

A. Changing the inner cannula on a tracheostomy: This procedure falls within the RN's scope of practice, as it involves basic tracheostomy care and maintenance, which nurses commonly perform.
B. Administering a platelet transfusion: Administering blood and blood products, including platelet transfusions, is within the RN's scope of practice, provided the nurse has appropriate training and competency.
C. Irrigation of an external ear canal: Irrigation of an external ear canal is a routine nursing procedure that falls within the RN's scope of practice, as long as it does not involve invasive procedures beyond irrigation.
D. Inserting a tunneled central venous catheter: Inserting tunneled central venous catheters is typically performed by advanced practice nurses or physicians with specific training and certification, such as nurse practitioners or interventional radiologists. This procedure is beyond the scope of practice for RNs and requires specialized skills and knowledge.

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A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

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