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 does not move."
"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
A. Attaching restraints to a non-moving part of the bed frame prevents injury when the head or foot of the bed is adjusted. This ensures that the tension on the restraint remains constant and does not accidentally tighten or pull on the client’s limb.
B. A quick-release knot must be used instead of a square knot to allow for immediate removal in the event of an emergency. Square knots are difficult to untie quickly and could jeopardize client safety if the client’s airway or circulation becomes compromised.
C. Restraints must typically be removed and the client’s skin and circulation assessed at least every 2 hours rather than every 4 hours. Frequent neurovascular checks and range-of-motion exercises are essential to prevent complications such as pressure injuries or nerve damage.
D. Restraint prescriptions cannot be written on a "PRN" or as-needed basis because they require a specific, time-limited order based on a current assessment. The provider must conduct a face-to-face evaluation and renew the prescription according to facility policy and regulatory standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Urinary retention 12 hours after a laminectomy is concerning but not immediately life-threatening.
B. A low-grade fever in a client with MRSA needs monitoring, but it is not the most urgent problem.
C. Starting chemotherapy for pancreatic cancer is important, but it is a planned treatment and not an acute priority.
D. An absent pedal pulse indicates impaired arterial circulation, which can quickly lead to tissue ischemia and necrosis. Restoring circulation is the highest priority according to the ABC (Airway, Breathing, Circulation) and urgent vs non-urgent frameworks.
Correct Answer is ["C","D","E"]
Explanation
Rationale:
A. Initiating IV access while a client with dementia is sleeping violates autonomy and informed consent—this is not advocacy.
B. Implementing a plan of care based on nursing goals reflects nursing practice, but advocacy focuses on protecting the client’s rights and wishes, not just following nursing objectives.
C. Providing written information about palliative care supports informed decision-making, which is a key aspect of advocacy.
D. Obtaining an interpreter ensures the client understands their care and can make informed decisions, which is an advocacy action.
E. Documenting a client’s refusal of medication respects and upholds the client’s autonomy, which is a form of advocacy.
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