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:
The client has four new medications is incorrect. While the addition of new medications may require monitoring and adjustment, it does not directly indicate a need for occupational therapy. Medication management is typically addressed by the healthcare provider or pharmacist.
Choice B Reason:
The client has extreme difficulty swallowing is incorrect. This finding suggests dysphagia, which may require intervention from a speech-language pathologist rather than an occupational therapist. Speech-language pathologists specialize in assessing and treating swallowing difficulties.
Choice C Reason:
The client is experiencing dysarthria is incorrect. Dysarthria refers to difficulty in speaking due to weakness or poor coordination of the muscles used for speech. While it may affect communication and daily activities, it is primarily addressed through speech therapy rather than occupational therapy.
Choice D Reason:
The client requires assistance getting dressed is correct. Difficulty with activities of daily living, such as dressing, bathing, and grooming, is within the scope of occupational therapy. Occupational therapists help clients regain independence in activities of daily living through interventions aimed at improving fine motor skills, coordination, and adaptive strategies. Referring the client to an occupational therapist can help address their dressing needs and promote independence in self-care activities.
Correct Answer is A
Explanation
Choice A Reason:
A sufficient supply of personal protective equipment is appropriate. Bioterrorism events can involve the deliberate release of biological agents, such as bacteria, viruses, or toxins, with the intent to cause harm to individuals or populations. In such events, personal protective equipment (PPE) is critical for protecting healthcare workers and first responders from exposure to infectious agents and toxins. Adequate supplies of PPE, including masks, gloves, gowns, and eye protection, are essential to ensure the safety of healthcare workers and to prevent the spread of infection.
Choice B Reason:
A network for communication between staff members and families, is important for coordinating care and providing updates during a disaster, but it is not the highest priority when addressing immediate safety concerns related to a bioterrorism event.
Choice C Reason:
A mental health specialist on the response team, is important for providing support to individuals affected by the disaster, but it is not the highest priority during the initial response phase focused on safety and containment.
Choice D Reason:
A system for tracking client information, is important for maintaining continuity of care and tracking patient outcomes, but it is not the highest priority in the immediate response to a bioterrorism event when protecting healthcare workers and preventing further spread of infection is paramount.
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