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?

"A provider can write a prescription for restraints 'as needed"."

"I should tie the restraints using a square knot."

"I need to tie the restraint to the part of the bed frame that moves."

"I will remove a client's restraints every 4 hours."

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Restraints should never be prescribed on an "as needed" basis (PRN). Each application of restraints requires a specific and current provider order.
Choice B Reason:
Apply the appropriate restraint, using a clove hitch or a square knot. When applying restraints, using a square knot is essential to ensure that the restraints remain secure but can be easily removed in case of an emergency. A square knot provides a balance between security and quick release when needed.
Choice C Reason:
Restraints should be tied to a non-movable part of the bed frame, not to a part that moves, to prevent injury to the client.
Choice D Reason:
Restraints should be checked and removed more frequently, typically every 2 hours, to assess the client’s skin integrity and circulation, and to provide range-of-motion exercises.

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Correct Answer is D

Explanation

Choice A Reason:
Demonstrating the proper client transfer technique for the AP, could be beneficial after ensuring the immediate safety of the client. However, providing immediate assistance to the client is the priority.
Choice B Reason:
Instructing the AP to request assistance when unsure about a task, is important for promoting a culture of safety and collaboration. However, in this scenario, the immediate focus is on assisting the client.
Choice C Reason:
Referring the AP to the facility procedure manual, may be helpful for providing additional guidance and education on proper techniques. However, in the moment, the nurse manager should prioritize immediate action to assist the client.
Choice D Reason:
Helping the AP assist the client with the transfer is correct. When a nurse manager observes an assistive personnel (AP) incorrectly performing a task such as transferring a client, the first priority is ensuring the safety and well-being of the client. Therefore, the nurse manager should intervene immediately to provide assistance and ensure that the client is transferred safely.

A. Shred extra copies of the client's records when they are no longer needed. B. Call the facility to confirm the fax number after sending the client's information. C. Avoid using a fax cover sheet in order to reduce paper waste. D. Send the facility a copy of the client's complete medical record.

Correct Answer is A

Explanation

Choice A Reason:
Shredding extra copies of a client's records is essential to maintaining confidentiality and protecting the client's privacy. This ensures that sensitive information is properly disposed of and cannot be accessed by unauthorized individuals.

Choice B Reason:
While confirming the fax number before sending the client's information is essential, doing so after sending the information is not useful and can potentially lead to privacy breaches if the information was sent to the wrong number. The correct action would be to verify the fax number before sending the information.

Choice C Reason:
Avoid using a fax cover sheet in order to reduce paper waste is inappropriate. While reducing paper waste is important for environmental sustainability, using a fax cover sheet is typically necessary for providing necessary information and ensuring that the fax is properly directed to the intended recipient. Omitting a fax cover sheet may lead to confusion or misdirection of the faxed information.

Choice D Reason:
Sending the facility, a copy of the client's complete medical record is inappropriate. While it may be necessary to send relevant portions of the client's medical record to the rehabilitative facility, sending the entire medical record may be excessive and could potentially violate the client's privacy rights. It's important to send only the information that is pertinent to the client's transfer and rehabilitation needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is preparing to fax information to a rehabilitative facility prior to transferring a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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a

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