A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

Ensure two fingers can fit between the device and the client.

Perform a neurovascular check every 2 hours.

Secure the restraint to the bedrail.

Obtain a prescription renewal every 72 hours.

Implement passive range-of-motion exercises.

Answer and Explanation

Correct Answer : A,B,D,E

A. Ensuring two fingers can fit between the device and the client is crucial for monitoring circulation and preventing skin breakdown.
B. Performing a neurovascular check every 2 hours is necessary to assess circulation and nerve function, ensuring that the restraint is not causing harm.
C. Securing the restraint to the bedrail is not appropriate; restraints should be secured to the movable part of the bed frame to avoid causing injury.
D. Obtaining a prescription renewal every 72 hours is required for ongoing restraints, as it ensures continued monitoring and justification for their use.
E. Implementing passive range-of-motion exercises is essential to maintain joint mobility and prevent complications associated with immobility.

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Correct Answer is D

Explanation

A. While human error contributes to adverse events, the focus of selecting surveillance systems is on prevention through technology rather than just acknowledging errors.
B. Although data systems can provide documentation, the primary goal of surveillance systems is to monitor and prevent events rather than serve as a backup.
C. Illegibility in documentation can lead to errors, but this option does not specifically address the role of surveillance technology in preventing adverse events.
D. Physiologic monitoring systems are designed to detect early physiological changes, which can help prevent adverse events before they occur, aligning with the aim of using technology effectively.

A. "No problem. Just log me off when you're done." B. "I'm sorry, but you will have to enter the information using your own password." C. "Just make sure that you sign your note because it's under my password." D. "I'll put the note in for you. What do you want to say?"

Correct Answer is B

Explanation

A. Allowing someone else to use your login credentials compromises patient confidentiality and violates privacy policies.
B. This response correctly emphasizes the importance of maintaining security and confidentiality in electronic health records. Each user must access the system using their credentials to ensure accountability.
C. Signing a note under someone else's password is not acceptable and could lead to misattribution of documentation.
D. Entering information on behalf of another person also violates policies regarding documentation and accountability.

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A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

As the head nurse involved in selecting which patient surveillance systems to acquire for your unit, one of your aims is to avoid adverse events through the implementation of appropriate technology. This particular aim recognizes that:

Correct Answer is D

Explanation

The clinic nurse has just accessed a client's chart on the computer. The resident comes over and asks her to stay logged on because he needs to add a note to that client's chart. She should say:

Correct Answer is B

Explanation

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