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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Verifying the spelling of the medication with the provider is correct. When receiving a telephone prescription, it's essential to verify the accuracy of the information provided, including the spelling of the medication. This helps prevent errors in transcription and dispensing. Verifying the spelling of the medication with the provider ensures that the nurse correctly identifies the medication being prescribed.
Choice B Reason:
Transcribing prescriptions received via a voicemail recording, may not be the safest method for obtaining prescriptions, as it may introduce transcription errors. Direct communication with the provider is preferred whenever possible.
Choice C Reason:
Requesting that the provider call prescriptions in to the pharmacy, may be appropriate in some cases, but it does not address the nurse's role in accurately receiving and documenting telephone prescriptions.
Choice D Reason:
Using standard abbreviations when obtaining a telephone prescription, is not recommended. Abbreviations can lead to misinterpretation and errors, so it's important to use clear and unambiguous language when documenting prescriptions.
Correct Answer is A
Explanation
Choice A Reason:
"I will have a client who is on airborne precautions wear a mask when out of her room." This statement demonstrates understanding of airborne precautions. Clients on airborne precautions, such as those with tuberculosis or measles, should wear a mask when they leave their room to prevent the spread of infectious droplets.
Choice B Reason:
"I will place a client who has compromised immunity in a negative-pressure airflow room." While placing a client with compromised immunity in a negative-pressure airflow room may be appropriate in some cases to reduce the risk of exposure to pathogens, it is not a standard precaution and is not applicable to all clients with compromised immunity.
Choice C Reason:
"I will instruct visitors to wear a mask when visiting a client who is on contact precautions." This statement indicates an understanding of contact precautions. Visitors should wear appropriate personal protective equipment, such as gloves and gowns, when visiting clients on contact precautions to prevent the transmission of infectious agents.
Choice D Reason:
"I will wear an N95 respirator mask when caring for a client who is on droplet precautions." This statement demonstrates understanding of droplet precautions. Healthcare providers should wear a surgical mask when caring for clients on droplet precautions, as it helps prevent the transmission of respiratory droplets generated by the client through coughing, sneezing, or talking. N95 respirator masks are typically reserved for airborne precautions.
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