A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?
Remove the restraints from the client.
Offer the client PRN pain medication.
Continue to monitor the client every 15 min.
Encourage the client to attend a group therapy session.
The Correct Answer is A
Rationale:
A. Remove the restraints from the client: Restraints should be discontinued as soon as the client no longer poses a danger to themselves or others. Prompt removal prevents unnecessary restriction and respects the client’s rights and dignity.
B. Offer the client PRN pain medication: While assessing for discomfort is important, pain medication is not the immediate priority once the client is calm and cooperative, unless the client requests it or shows signs of pain.
C. Continue to monitor the client every 15 min: Monitoring should continue after restraint removal according to facility policy, but the first action is to remove the restraints to avoid unnecessary confinement.
D. Encourage the client to attend a group therapy session: While therapeutic activities are important, this is not the immediate action following restraint use. Ensuring the client’s safety and removing restraints takes priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Report bleeding that saturates the client's dressing.": Excessive or saturating bleeding from a postoperative abdominal incision may indicate hemorrhage or disruption of the surgical site and requires immediate provider notification.
B. "Ensure the client's urinary output is no less than 20 mL per hour.": The expected minimum urinary output for an adult after surgery is at least 30 mL per hour, which reflects adequate renal perfusion and fluid balance. A urine output of 20 mL per hour is too low.
C. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected postoperatively and may signal urinary retention, a common complication due to anesthesia or opioids.
D. "Maintain the client in a supine position for 24 hours following surgery.": Keeping the client supine for 24 hours increases the risk of respiratory complications, including atelectasis and pneumonia. The nurse should encourage early ambulation and semi-Fowler’s positioning.
Correct Answer is C
Explanation
Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.
B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.
C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.
D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.
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