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
A. Convey the client's request to the nurse who witnessed the consent.The nurse who witnessed the consent does not have the authority to explain the risks of the procedure. Their role is only to witness that the consent was signed, not to provide information about the procedure.
B. Notify the provider about the client's concerns.The provider who is performing the cardiac catheterization is legally responsible for explaining the risks, benefits, and alternatives of the procedure. If the client expresses concerns or appears to lack understanding just before the procedure, the nurse should notify the provider so they can further explain the risks and clarify any questions.
C. Explain the risks of the procedure to the client.While the nurse can offer general information about the procedure, only the provider who is performing the procedure should explain the specific risks associated with it.
D. Check to see if the medical record indicates the provider explained the procedure to the client. Even if documentation indicates that the provider previously explained the procedure, the client still has the right to have their concerns addressed by the provider just before the procedure.
Correct Answer is C
Explanation
Choice A Reason:
Replacing total parenteral nutrition solution bags every 48 hr is incorrect. Total parenteral nutrition (TPN) solution bags typically need to be replaced more frequently than every 48 hours to prevent bacterial contamination and ensure the integrity of the solution. However, the frequency of bag changes may vary depending on institutional protocols and specific patient needs.
Choice B Reason:
Replacing peripheral IV solution bags every 96 hr is incorrect. Peripheral IV solution bags may be changed less frequently than every 96 hours, as long as the solution remains sterile and the integrity of the infusion system is maintained. However, the frequency of bag changes may vary based on institutional policies and patient-specific factors.
Choice C Reason:
Changing peripheral IV primary tubing every 96 hr is correct. Changing peripheral IV primary tubing every 96 hours is a recommendation consistent with infection control guidelines and helps prevent contamination and bloodstream infections. This practice is cost-effective while ensuring patient safety.
Choice D Reason:
Changing total parenteral nutrition IV tubing every 48 hr is incorrect. Total parenteral nutrition (TPN) IV tubing typically needs to be changed more frequently than every 48 hours to prevent bacterial contamination and ensure the integrity of the TPN solution. However, the frequency of tubing changes may vary depending on institutional protocols and patient-specific factors.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
