A nurse is caring for a client who is disoriented and is continuously getting out of bed. Which of the following actions should the nurse take? (Select all that apply.)
Only use restraints if the client becomes violent.
Use seclusion to manage the client's behavior.
Attempt the use of less restrictive methods before using restraints.
Use restraints for the minimum amount of time necessary.
Ensure the restraint limits the client's movement as little as possible.
Correct Answer : C,D,E
A. Only use restraints if the client becomes violent: Restraints should be used as a last resort when the client poses a danger to themselves or others. They are not meant for convenience or managing disorientation alone.
B. Use seclusion to manage the client's behavior: Seclusion is typically reserved for managing severe aggression or self-harm in psychiatric settings. It is not an appropriate first-line intervention for a disoriented client attempting to get out of bed.
C. Attempt the use of less restrictive methods before using restraints: The nurse should first implement interventions such as frequent monitoring, bed alarms, or sitter assistance. This approach prioritizes client safety while respecting autonomy and minimizing harm.
D. Use restraints for the minimum amount of time necessary: If restraints are applied, they must be removed as soon as it is safe to do so to prevent physical and psychological complications, adhering to best practice and regulatory guidelines.
E. Ensure the restraint limits the client's movement as little as possible: Proper application of restraints focuses on safety while allowing maximum mobility and comfort. Overly restrictive restraints can cause injury, skin breakdown, and additional stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will regulate the oxygen flow rate as needed.": Clients should never change their prescribed oxygen flow rate independently. Altering the rate without guidance can lead to hypoxemia if too low or oxygen toxicity if too high.
B. "I will store oxygen tanks in an upright position.": Oxygen cylinders should always be stored upright and secured to prevent tipping, which could cause the cylinder to become a dangerous projectile. This demonstrates safe handling of compressed oxygen.
C. "I should check the oxygen equipment once per week.": Oxygen equipment should be checked daily for function, cleanliness, and safety. Weekly checks are insufficient and could allow unnoticed malfunctions to compromise oxygen delivery.
D. "I should place the oxygen equipment 4 feet from a heat source.": Oxygen equipment should be kept at least 8 feet away from open flames, heaters, or other heat sources. Four feet is too close and increases the risk of fire hazards.
Correct Answer is A
Explanation
A. 30° lateral: The 30-degree lateral position is recommended to reduce pressure on bony prominences such as the trochanters, sacrum, and heels. It distributes weight more evenly and decreases the risk of pressure injury compared to lying directly on the side or back.
B. Lateral semi-prone recumbent: This position places significant pressure on the greater trochanter and shoulder, which increases the risk of skin breakdown. It is not the safest choice for clients at high risk of pressure injuries.
C. Supine: Lying flat on the back concentrates pressure on the sacrum, heels, and occiput. Prolonged supine positioning without frequent repositioning contributes to rapid development of pressure injuries.
D. 45° supported Fowler's: While Fowler’s position can help with breathing, it increases pressure on the sacrum and ischial tuberosities. Extended use in this position places immobile clients at a greater risk for pressure injuries.
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