A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?
Document in the client's medical record every 15 min.
Offer toileting to the client every 4 hr.
Remove the restraint when the client falls asleep.
Request that the provider write an as-needed prescription for restraints.
The Correct Answer is A
A. Documenting in the client's medical record every 15 minutes is essential to monitor the client's status, including physical and psychological well-being, while in restraints. Accurate documentation ensures that any changes or responses to the intervention are recorded and communicated to other healthcare providers.
B. Offering toileting to the client every 4 hours may be necessary depending on the client's
individual needs, but it does not address the immediate need for monitoring the client's safety and well-being while restrained.
C. Removing the restraint when the client falls asleep is not appropriate without a healthcare provider's order. Restraints should only be removed based on a specific criteria set forth by
institutional policies or as directed by the healthcare provider.
D. Requesting an as-needed prescription for restraints is not appropriate. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a healthcare provider's assessment and orders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Massaging around the edge of the cast with lotion can lead to skin breakdown and should be avoided.
B. Elevating the extremity helps reduce swelling, promotes venous return, and decreases the risk of complications such as compartment syndrome.
C. Instructing the client to insert objects under the cast is unsafe and can cause skin injury or infection.
D. Numbness in the toes is not expected; it can indicate impaired circulation or nerve damage and should be reported immediately.
Correct Answer is D
Explanation
A. Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not effectively breastfeeding and may not be getting enough milk.
B. Having three wet diapers each day is an important indicator of hydration but does not directly correlate with effective breastfeeding.
C. Having a bowel movement every other day may vary depending on the newborn's age and feeding patterns and is not necessarily an indicator of effective breastfeeding.
D. Audible swallowing sounds during breastfeeding indicate that the newborn is effectively latching onto the breast and extracting milk. This suggests that the newborn is receiving an adequate amount of milk during feeding sessions.
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