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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. The nurse wears an N95 respirator when performing client care: Measles is highly contagious and spreads through respiratory droplets. Wearing an N95 respirator provides appropriate respiratory protection for the nurse when caring for a client with measles. This action is appropriate and does not require intervention by the charge nurse.
B. The nurse places the client on airborne precautions: Measles is transmitted via airborne droplets, so placing the client on airborne precautions is necessary to prevent the spread of the disease to others. This action is appropriate and aligns with infection control guidelines.
C. The nurse ensures the client's room maintains a positive airflow: Positive airflow can potentially contribute to the spread of airborne pathogens outside the room, increasing the risk of transmission to others. For clients with airborne infections like measles, negative airflow rooms are required to minimize the risk of transmission to healthcare workers and other clients. Therefore, the charge nurse should intervene and correct this action.
D. The nurse has the client wear a mask for transport to radiology: Having the client wear a mask during transport helps minimize the spread of infectious droplets to others in the facility. This action is appropriate and aligns with infection control measures for airborne precautions

A. Add water to the formula. B. Reposition the NG tube. C. Increase the rate of formula delivery. D. Switch to a lactose-free formula.

Correct Answer is A

Explanation

A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

Correct Answer is C

Explanation

A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?

Correct Answer is A

Explanation

A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referrals should the nurse anticipate for this client?

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?

A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?