A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)
The provider should renew the prescription for restraints every 48 hr.
The nurse should pad the bony prominences.
The nurse should tie the restraints using a square knot.
The nurse should remove the restraints every 2 hr.
The provider's prescription should include the type of restraint to use.
Correct Answer : B,D,E
A. The provider should renew the prescription for restraints every 24 hours, not 48 hours.
B. Padding bony prominences helps prevent skin breakdown and pressure injuries.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in an emergency.
D. Removing the restraints every 2 hours allows for circulatory assessment, skin care, and range of motion exercises.
E. The provider's prescription should specify the type of restraint to ensure proper and appropriate use.
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Related Questions
Correct Answer is A
Explanation
A.
A. It's important to include the complete name of the medication to ensure clarity and accuracy in documentation.
B. Omitting the leading zero before a decimal point can lead to medication errors, so it's important to include it.
C. "U" is commonly used to denote units when documenting insulin dosage, so this statement is accurate.
D. "QOD" is an outdated abbreviation and can lead to confusion, so it should not be used; instead, "every other day" should be written out for clarity.
Correct Answer is D
Explanation
A. Routine activities such as daily baths are not typically pertinent information to include in a change-of-shift report unless they have a significant impact on the client's condition or care.
B. While vomiting after surgery may be noteworthy, the timing and amount of emesis
immediately after surgery may not be relevant to the client's current condition, especially if it was an isolated incident.
C. Flushing the IV with normal saline is a routine nursing intervention and may not be necessary to report unless there were specific concerns or complications related to the IV.
D. Pain relief is an important aspect of postoperative care and should be included in the report to ensure continuity of care and appropriate pain management for the client.
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