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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. The lecithin/sphingomyelin (L/S) ratio test is not used to detect birth defects. It specifically assesses fetal lung maturity by measuring the ratio of two phospholipids present in fetal lung surfactant.
B. The L/S ratio test does not reveal the sex of the fetus. It is unrelated to fetal gender determination.

C. While preterm labor risk can be assessed through other methods, such as cervical length

measurement or fetal fibronectin testing, the L/S ratio test is specifically focused on fetal lung maturity.
D. The L/S ratio test is primarily used to determine fetal lung maturity, as an increased ratio indicates lung maturity and readiness for extrauterine life.

A. "If my baby doesn't finish a bottle of formula, I will let him finish it at the next feeding." B. "I will position my baby on his stomach after feedings." C. "I will feed my baby six to eight times a day." D. "if my baby doesn't seem satisfied after a feeding, I will add rice cereal to his next bottle."

Correct Answer is C

Explanation

A. Incorrect. Allowing the baby to finish a bottle at the next feeding increases the risk of overfeeding and can lead to problems such as excessive weight gain and discomfort.
B. Incorrect. Placing the baby on their stomach after feedings increases the risk of choking and is not recommended. The correct position is to place the baby on their back to sleep.
C. Correct. Newborns typically need to be fed approximately every 2-3 hours, which amounts to about six to eight feedings per day. This statement indicates an understanding of the frequency of feeding required for a newborn.
D. Incorrect. Adding rice cereal to a newborn's bottle is not recommended, especially without medical advice, as it can increase the risk of choking and may not be developmentally appropriate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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