A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

Attach the restraints to the fixed portions of the frame of the client's bed.

Remove the client's restraints every 2 hr

Secure the client's restraints with a square knot.

Allow 1 fingerbreadth between the restraint and the client's wrists.

Answer and Explanation

The Correct Answer is D

A.   Restraints should not be attached to the bed frame. Instead, they should be secured to a movable part of the bed (such as side rails) to prevent injury. Attaching restraints to the bed frame can cause harm to the patient and limit their mobility.
B.   While it's essential to assess and reposition restraints regularly, removing them entirely every 2 hours is not recommended unless the patient's condition allows for it. Restraints should be removed and repositioned at least every 2 hours to assess skin integrity, circulation, and comfort. However, they should not be removed entirely unless necessary.
C.   Square knots are not recommended for restraining patients because they can be difficult to untie quickly in case of an emergency. Quick-release buckles or Velcro fasteners are safer options.
D.   Allowing 1 fingerbreadth between the restraint and the client's wrists ensures proper circulation and prevents excessive tightness. Properly fitting restraints prevent injury while maintaining patient safety.

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Correct Answer is D

Explanation

A. While the oldest adult child may have durable power of attorney for health care, this authority only comes into play if the client is unable to make their own health care decisions. Since the client is oriented to person, place, and time, they are considered competent to make their own decisions.
B. The partner may have emotional and personal interests in the client's health care decisions, but legal authority to make health care decisions generally does not extend to the partner unless specifically designated in advance directives or legal documents. In the absence of such designations and if the client is competent, the partner does not have the legal authority to make decisions.
C. The provider’s role is to offer recommendations and information about the benefits and risks of treatment options. However, the provider does not have the legal authority to make health care decisions on behalf of the client, even if they recommend surgery or other treatments.
D. The client, being oriented to person, place, and time, is competent to make their own health care decisions. In such cases, the client’s wishes take precedence over any advance directives or powers of attorney, as long as they are able to understand and make informed decisions about their care.

A. Demonstrate use of the pump during medication administration. B. Assess the staff nurses' knowledge deficit. C. Pair an inexperienced nurse with an experienced nurse. D. Plan an in-service education program on the unit

Correct Answer is B

Explanation

A. While demonstrating the use of the pump can be helpful and provide immediate support, it does not address the underlying issue of why the staff nurses are struggling with the pumps.
B. Assessing the staff nurses' knowledge deficit is the most appropriate first step. Understanding specifically where the gaps in knowledge or skills lie allows the charge nurse to tailor interventions effectively. This assessment can identify whether the issue is due to a lack of training, misunderstanding of the pump’s features, or other factors.
C. Pairing inexperienced nurses with experienced ones can be a beneficial strategy for on-the-job training and support. However, this action assumes that the experienced nurse has the necessary knowledge and skills and that pairing will solve the problem.
D. Planning an in-service education program is a proactive approach to improving overall staff competency with the new IV infusion pumps. However, this action should follow the assessment of the specific knowledge deficits.

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A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?

Correct Answer is B

Explanation

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