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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. 65 mL: The total liquid intake includes 30 mL of water used to flush the NG tube before the medication, 5 mL of medication instilled, and 30 mL of water used to flush the tube afterward. Adding these together gives 65 mL, which accurately reflects all fluids administered.

B. 5 mL: Documenting only the medication omits the water used for flushing, underrepresenting the client’s total fluid intake.

C. 35 mL: This amount accounts only for the post-flush water and medication, it ignores the pre-flush water, resulting in an inaccurate intake record.

D. 60 mL: This underestimates the total intake by failing to include all three components correctly; precise documentation is essential for fluid balance monitoring.

A. Schedule the client as the last surgery of the day. B. Notify ancillary departments of the client's allergy. C. Label the surgical suite as latex-free. D. Provide powdered gloves for the staff's use. E. Ensure a latex allergy cart is available.

Correct Answer is ["B","C","E"]

Explanation

A. Schedule the client as the last surgery of the day: Clients with latex allergy should ideally be scheduled as the first surgery of the day to minimize exposure to latex particles that may accumulate in the air and environment. Scheduling last increases exposure risk.

B. Notify ancillary departments of the client's allergy: Informing all relevant departments, such as pharmacy, radiology, and laboratory services, ensures that latex-free supplies are used consistently throughout the client’s care. This prevents accidental exposure to latex-containing products.

C. Label the surgical suite as latex-free: Clearly labeling the operating room reduces the risk of staff inadvertently bringing in latex products. It promotes team-wide awareness and helps maintain a safe surgical environment for the client.

D. Provide powdered gloves for the staff's use: Powdered latex gloves are contraindicated because they release latex proteins into the air, which increases the risk of allergic reactions. Only non-latex, powder-free gloves should be provided.

E. Ensure a latex allergy cart is available: Having a latex allergy cart stocked with latex-free supplies ensures that all necessary items are available during the procedure. This reduces delays and eliminates the need to search for suitable equipment during surgery.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has administered 5 mL of medication to a client via NG tube. They used 30 mL of water to flush the tube both before and after the instillation. The nurse should document which of the following amounts as liquid intake for the client?

Correct Answer is A

Explanation

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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A nurse is caring for a client who is pulling at their abdominal wound drains. The provider prescribes wrist restraints for the client's safety. To which of the following parts of the bed should the nurse secure the restraints?