A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I need to tie the restraint to the part of the bed frame that moves."
"I should tie the restraints using a square knot."
"I will remove a client's restraints every 4 hours."
"A provider can write a prescription for restraints as needed."
The Correct Answer is A
Rationale:
A. Restraints should always be tied to a part of the bed frame that moves with the client (not to side rails), using a quick-release knot to ensure client safety.
B. A square knot is unsafe because it is difficult to untie quickly in an emergency. Quick-release knots should be used instead.
C. Restraints must be removed at least every 2 hours (not every 4) to assess skin, circulation, and provide ROM exercises.
D. A provider’s prescription for restraints must be time-limited and specific; prescriptions "as needed" (PRN) are not allowed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Home health provides ongoing nursing care and monitoring in the home but does not typically arrange for durable medical equipment like a wheelchair.
B. Social services coordinate community resources, including arranging for durable medical equipment such as a wheelchair, making this the correct referral.
C. Physical therapy focuses on improving strength, mobility, and teaching the client how to safely transfer and use mobility aids but does not arrange for equipment procurement.
D. Occupational therapy helps the client adapt to activities of daily living (ADLs) and may train the client in wheelchair use but does not arrange for obtaining the wheelchair itself.
Correct Answer is D
Explanation
Rationale:
A. A client discharged after a minor outpatient procedure typically has straightforward needs and does not require a case manager.
B. Requesting a provider’s note is a simple administrative task that does not require case management.
C. Requesting a change in pain medication involves provider communication and nursing assessment but does not necessitate a case manager.
D. A client transferring from acute care to a rehabilitation facility often has complex care needs, multiple providers, and coordination requirements, making a case manager essential to facilitate continuity of care.
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