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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.

B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.

C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.

D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.

A. Hallucinations B. Agnosia C. Bradycardia D. Aphasia

Correct Answer is A

Explanation

A. Hallucinations - Delirium can cause perceptual disturbances such as hallucinations, where the client perceives things that are not actually present.

B. Agnosia - Agnosia refers to the inability to recognize familiar objects, which is not typically associated with delirium.

C. Bradycardia - Delirium is not typically associated with bradycardia; it may actually be associated with tachycardia due to the physiological stress response.

D. Aphasia - Aphasia refers to the loss of ability to understand or express speech, which is not typically associated with delirium.

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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.)

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