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 D
Explanation
Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.
Correct Answer is ["A","C"]
Explanation
Choice A Reason:
Providing written information to a client regarding palliative care is correct. Advocating for the client's autonomy and right to information by providing written materials about palliative care empowers the client to make informed decisions about their care.
Choice B Reason:
Documenting a client's refusal to take a prescribed medication is incorrect. While documenting a client's refusal is important for accurate medical records, it is not an example of advocacy. Advocacy involves actively supporting the client's rights, preferences, and needs.
Choice C Reason:
Obtaining an interpreter for a client who speaks a different language than the nurse is correct. Advocating for effective communication ensures that the client can fully understand and participate in their care, regardless of language barriers. Obtaining an interpreter facilitates communication and promotes the client's right to understand and be understood.
Choice D Reason:
Initiating IV access on a client who has dementia while he is sleeping is incorrect. This scenario raises ethical concerns as it involves performing a procedure on a client who is unable to provide consent due to being asleep and having dementia. Without explicit consent or a medical emergency necessitating immediate intervention, initiating IV access in this situation may not align with client advocacy principles.
Choice E Reason:
Implementing a client's plan of care based upon nursing goals is incorrect. While implementing a client's plan of care is part of the nurse's role, it is not necessarily an example of advocacy. Advocacy involves actively promoting and safeguarding the client's rights, preferences, and well-being, which may sometimes involve advocating for modifications to the plan of care based on the client's needs and goals.
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