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 B
Explanation
Choice A Reason:
"I will be given contrast dye during this test." This statement is incorrect. Pulmonary function tests typically do not involve the use of contrast dye, as they focus on measuring lung function rather than visualizing anatomical structures.
Choice B Reason:
"I might have to wear a nose clip during this test." This statement is correct. Nose clips are commonly used during pulmonary function tests to ensure that air is only breathed in and out through the mouth, allowing for accurate measurement of lung function parameters.
Choice C Reason:
"I might have a tube inserted into my airway during this test." This statement is incorrect. While this statement reflects a potential misunderstanding or confusion about the procedure, it is not typically the case for a routine pulmonary function test. Invasive procedures such as bronchoscopy may involve inserting a tube into the airway, but it is not part of a standard pulmonary function test.
Choice D Reason:
"I will run on a treadmill during this test." This statement is incorrect. Pulmonary function tests do not involve physical exercise like running on a treadmill. Instead, they typically involve breathing maneuvers and measurements to assess lung function.
Correct Answer is D
Explanation
Choice A Reason:
Fidelity is inappropriate. Fidelity refers to the obligation to fulfill commitments and responsibilities. While important in maintaining trust and professional relationships, fidelity may not directly apply to the situation described.
Choice B Reason:
Nonmaleficence is inappropriate. Nonmaleficence is the principle of doing no harm. In this situation, ensuring the safety and well-being of the client is paramount, and failing to use a gait belt could potentially lead to harm. However, the primary issue in this scenario is the accuracy and completeness of the incident report rather than the act of causing harm.
Choice C Reason:
Beneficence is inappropriate. Beneficence is the principle of doing good and acting in the best interest of the client. While ensuring the use of a gait belt aligns with promoting the client's safety and well-being, the primary concern in this scenario is the integrity and honesty in reporting the incident accurately.
Choice D Reason:
Veracity is appropriate. Veracity refers to truthfulness and honesty. In this situation, the charge nurse should ensure that the incident report accurately reflects the circumstances of the fall, including the absence of the gait belt. Being truthful and transparent in reporting incidents is essential for maintaining trust, promoting accountability, and improving patient safety.
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