A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?
Offer the client fluids and toileting every 15 min.
Obtain a prescription before removing the restraints.
Ensure the restraints are removed from the client within 6 hr.
Place the client in prone position on a soft mattress.
The Correct Answer is B
Rationale:
A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.
B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.
C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.
D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
Rationale:
- Ask the client for a list of close contacts: The client exhibits classic symptoms of active tuberculosis (TB), including weight loss, night sweats, hemoptysis (bloody cough), and chest tightness. Identifying close contacts is crucial for contact tracing and limiting disease spread.
- Obtain a sputum culture: A sputum culture is essential for diagnosing pulmonary TB. This test confirms the presence of Mycobacterium tuberculosis and guides further treatment decisions.
- Place the client in a negative-pressure room: Clients suspected of having TB should be placed in a negative-pressure isolation room to prevent airborne transmission to others, especially in healthcare settings.
- Use airborne precautions: Airborne precautions, including the use of an N95 respirator, are required for suspected or confirmed TB due to its airborne transmission risk.
- Obtain blood cultures: Blood cultures are not the priority in TB diagnosis unless sepsis is suspected. TB is primarily diagnosed through respiratory samples, not blood.
- Recommend ABGs be drawn: Arterial blood gases (ABGs) are typically unnecessary in TB unless there is respiratory compromise requiring ventilatory support or oxygenation monitoring, which is not indicated here.
- Request a glucocorticoid prescription from the provider: Glucocorticoids are not standard treatment for TB and may suppress immune response. They may be used in specific TB complications like meningitis or pericarditis, but not in general pulmonary TB management.
Correct Answer is B
Explanation
Rationale:
A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.
B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.
C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.
D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.
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