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 ["A","B","C","D","E"]
Explanation
Correct answers:
Nurses Notes Day 1, 1600:
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 150/min, ECG monitor showing sinus tachycardia, 5, auscultated. Lower extremity edema noted, 2+ bilaterally. Radial and pedal pulses 1 bilaterally. Breathing rapid and shallow. Cracklesauscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining "10 pounds in the past month."
Correct Answer is A
Explanation
A. Correct. Neostigmine is an acetylcholinesterase inhibitor that improves muscle strength by increasing the availability of acetylcholine at the neuromuscular junction, thereby enhancing muscle contraction.
B. Incorrect. Neostigmine does not destroy the antibodies that cause MG. MG is an autoimmune disorder characterized by antibodies that block or destroy acetylcholine receptors, leading to muscle weakness.
C. Incorrect. Neostigmine does not enhance immune system function. It works specifically on the neuromuscular junction to improve muscle strength in MG.
D. Incorrect. While neostigmine may indirectly help prevent excessive coughing by improving respiratory muscle strength in clients with MG, preventing coughing is not its primary action.
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