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 {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Admission notes: Knowledge
Admission notes provide insights into the patient's medical history and current condition, which requires understanding and context, indicating knowledge.
Orders: Wisdom
The orders reflect clinical judgment and decision-making based on the patient's condition and needs, indicating wisdom.
Laboratory findings: Data
Laboratory findings present measurable results (e.g., blood glucose, serum ketones, pH), representing raw data.
Patient profile: Data
The patient profile includes demographic information and medical history, which are factual data points.
Vital signs: Data
Vital signs are quantitative measurements that provide objective data on the patient's physiological status.

A. Ignore Ellen's errors until she has more experience. B. Ask Ellen to complete a self-assessment, using a standard skills checklist. C. Instruct staff to avoid working with Ellen until she learns to do things herself. D. Encourage staff to report every behavior of Ellen's that is different from theirs.

Correct Answer is B

Explanation

A. Ignoring Ellen's errors does not support her development and may lead to continued mistakes that could affect patient care and team dynamics.
B. A self-assessment using a standard skills checklist allows Ellen to reflect on her skills, identify areas needing improvement, and take ownership of her learning process. This approach encourages self-directed learning and accountability.
C. Instructing staff to avoid working with Ellen can foster isolation and hinder her development by denying her opportunities for mentorship and guidance.
D. Encouraging staff to report Ellen’s behaviors can create a negative environment, fostering distrust and discouraging collaboration rather than supporting her growth.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Ellen is a novice nurse on your unit. As her supervisor, you notice Ellen's knowledge and skill deficiencies. These deficiencies have been noticed by her peers as well. Which of the following is likely to be the greatest asset to Ellen in improving her performance?

Correct Answer is B

Explanation

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