A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Hold a critical incident debriefing about the client.

Observe the client’s range of movement.

Maintain sensory stimulation for the client.

Identify stressors that caused the client’s aggression.

Answer and Explanation

The Correct Answer is B

Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.

Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.

Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.

Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.

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Correct Answer is A

Explanation

Choice A reason: Checking IV pump cords for fraying ensures electrical safety, preventing shocks or malfunctions, critical for client and staff safety. This routine inspection is essential for equipment reliability, supporting safe infusion delivery, and adhering to hospital safety protocols in managing IV therapy for clients.

Choice B reason: Removing the safety inspection sticker is inappropriate; it verifies equipment safety. Checking cords is correct. Assuming sticker removal is needed risks using unverified equipment, potentially causing malfunctions, critical to avoid in ensuring safe IV pump operation for client infusions.

Choice C reason: Grasping the cord to unplug risks damage or shock; the plug should be held. Checking cords is priority. Assuming cord grasping is safe risks electrical hazards, critical to prevent in ensuring safe handling and operation of IV pumps in client care settings.

Choice D reason: Two-prong outlets are outdated; medical equipment requires three-prong grounded outlets. Checking cords is key. Assuming two-prong outlets are safe risks electrical hazards, critical to avoid in ensuring proper IV pump function and safety for clients receiving infusions in healthcare settings.

A. Reposition the NG tube. B. Inject 20 mL of air and aspirate in the NG tube. C. Instill an irrigation solution slowly. D. Check the functioning of the suction equipment.

Correct Answer is D

Explanation

Choice A reason: Repositioning the NG tube is a later step; checking suction function is first, as equipment failure is a common cause of no drainage. Assuming repositioning is initial risks delaying simple fixes, potentially prolonging discomfort, critical to avoid in ensuring effective gastric decompression.

Choice B reason: Injecting air and aspirating is a troubleshooting step but follows checking suction equipment, which may resolve no drainage. Assuming air injection is first risks unnecessary intervention, potentially causing discomfort, critical to prevent in ensuring efficient NG tube management for gastric decompression.

Choice C reason: Instilling irrigation solution is a later step after confirming suction function, as equipment issues are more common. Assuming irrigation is first risks clogging or discomfort, critical to avoid in ensuring proper NG tube function and effective gastric decompression in clients with non-draining tubes.

Choice D reason: Checking suction equipment function is the first step for a non-draining NG tube, as equipment failure is a common issue, easily corrected. This ensures effective decompression, critical for preventing gastric distention, supporting client comfort, and guiding further troubleshooting in managing NG tube care.

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A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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