A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
Document the client’s condition every 15 min.
Request a PRN restraint prescription for clients who are aggressive.
Attach the restraint to the bed’s side rails.
Remove the client’s restraint every 4 hr.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Documenting the client’s condition every 15 minutes is a crucial part of using restraints. Regular documentation helps ensure the safety and well-being of the client, as it allows for continuous monitoring and timely intervention if necessary.
Choice B rationale:
Requesting a PRN (as needed) restraint prescription for clients who are aggressive is not a recommended practice. Restraints should only be used as a last resort and must be based on a thorough assessment of the client’s condition, not solely on their behavior.
Choice C rationale:
Attaching the restraint to the bed’s side rails is not recommended. This can increase the risk of injury to the client. Restraints should be attached to a part of the bed frame that moves with the client, such as the head or footboard.
Choice D rationale:
While it’s important to regularly check and adjust restraints for comfort and safety, there’s no specific guideline that restraints should be removed every 4 hours. The frequency of removal and repositioning will depend on the individual client’s condition and needs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Administer sublingual nitroglycerin.
Nitroglycerin is a vasodilator that can relieve chest pain caused by myocardial ischemia. The nurse should administer it as soon as possible to improve blood flow to the heart and reduce the risk of myocardial infarction. The nurse should also monitor the client’s blood pressure and heart rate after giving nitroglycerin, as it can cause hypotension and reflex tachycardia.
Choice A is wrong because checking a STAT cardiac troponin is not the first priority.
Cardiac troponin is a biomarker that indicates myocardial injury, but it may not rise until several hours after the onset of chest pain.
Therefore, it is not useful for immediate diagnosis or treatment of acute coronary syndrome. Choice B is wrong because requesting a prescription for a beta-blocker is not the first priority.
Beta-blockers are medications that can lower blood pressure and heart rate, and reduce the oxygen demand of the heart.
They can prevent or reduce the recurrence of chest pain and complications of acute coronary syndrome, but they are not indicated for immediate relief of chest pain.
Choice D is wrong because administering oxygen is not the first priority.
Oxygen therapy can increase the oxygen supply to the heart and reduce ischemia, but it is not necessary for all clients with chest pain.
Oxygen therapy should be based on the client’s oxygen saturation level and clinical condition.
If the client’s oxygen saturation is normal or high, oxygen therapy may not be beneficial and may even be harmful.
Correct Answer is ["C","E"]
Explanation
Preterm pre-labor rupture of membranes (PROM) is the spontaneous rupture of the amniotic sac before the onset of labor in a pregnancy less than 37 weeks gestation. It can lead to
infection, cord prolapse, placental abruption, and preterm delivery. The client has risk factors for PROM such as a history of preterm birth and a current infection indicated by fever.
Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. The client has signs of sepsis such as fever, tachycardia, and possible organ dysfunction. The client may have a urinary tract infection, a common cause of sepsis in pregnancy, or an intrauterine infection due to PROM or other factors.
Preeclampsia is not a likely complication for this client because she does not have high blood pressure or proteinuria, which are the defining features of preeclampsia. Seizures are not a likely complication for this client because she does not have epilepsy or eclampsia, which are the leading causes of seizures in pregnancy. Placenta previa is not a likely complication for this client because she does not have painless vaginal bleeding, which is the hallmark symptom of placenta previa.
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