A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Remove one restraint at a time.
Tie the restraints to the side rail,
Secure restraints with a square knot
Remove the restraints every 3 hr
The Correct Answer is A
When using restraints for the safety of the client and others, it is important to follow proper procedures to ensure the client's well-being and minimize the risk of injury. Removing one restraint at a time allows for better control and assessment of the client's behavior and response. It also helps maintain the client's safety by ensuring that at least one limb is restrained during the process.
Restraints should never be tied to the side rail as it can cause serious harm or injury to the client. Restraints should be attached to an immobilization device specifically designed for that purpose, such as a bed frame or a designated restraint chair.
Restraints should be secured with a quick-release mechanism, such as a buckle or Velcro, that allows for quick and easy removal in case of emergency or the need for rapid intervention. Tying restraints with a square knot can delay the removal process and may compromise the client's safety.
Restraints should only be used when necessary and as prescribed by the healthcare provider. The frequency and duration of restraint use should be based on the client's condition and the specific order from the healthcare provider. It is not appropriate to remove restraints based solely on a time schedule without considering the client's individual needs and safety. Regular assessments should be conducted to determine if continued use of restraints is required or if alternative interventions can be implemented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Schedule postural drainage after meals.
Postural drainage should be performed at least 1 hour before or 2 hours after meals to avoid discomfort or aspiration.
B. Instruct the client to exhale quickly during vibration.
The client should exhale slowly during vibration to avoid forcing air too quickly into the lungs, which can be uncomfortable.
C. Cover the area of percussion with a towel
Percussion should be done with a towel or soft cloth to avoid skin irritation or injury while still allowing the vibrations to pass through.
D. Perform percussion over the lower back.
Percussion should not be performed over bony areas such as the spine or kidneys. The nurse should focus on the upper chest, lower chest, and upper back but avoid the lower back area.
Correct Answer is C
Explanation
A. Change the tubing set every 72 hr:
Enteral feeding sets should generally be changed every 24 hours to reduce the risk of bacterial contamination.
B. Heat the formula to 40.5° C (105° F):
Enteral formula should be administered at room temperature. Heating it can alter the composition and pose a burn risk to the gastrointestinal mucosa.
C. Aspirate residual volume every 4 hr:
This is recommended to assess tolerance to the feeding and prevent complications like aspiration. Holding feedings may be considered based on facility policy if residuals are high.
D. Flush the tubing with 10 mL of water every 2 hr:
While flushing is necessary to maintain patency, the typical flush is 30 mL every 4 hr (or before and after medications/feedings), unless otherwise specified.
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