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

Answer and Explanation

The Correct Answer is A

When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:

A) Document the client’s condition every 15 min

Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:

B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.

C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.

D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.

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Correct Answer is A

Explanation

The correct answer is A.

Weight loss.

Furosemide is a loop diuretic that is used to treat fluid volume excess by increasing the excretion of water and electrolytes through the kidneys. Weight loss is an indication that the medication has been effective in reducing the excess fluid in the body.

Choice B is wrong because decreased inflammation is not a direct effect of furosemide.

Inflammation is a response to tissue injury or infection, and furosemide does not have any anti-inflammatory properties.

Choice C is wrong because increased blood pressure is not an indication of furosemide effectiveness.

Furosemide lowers blood pressure by reducing the preload and afterload on the heart.

Increased blood pressure may indicate that the dose of furosemide is insufficient or that there are other factors contributing to hypertension.

Choice D is wrong because decreased pain is not an expected outcome of furosemide therapy.

Furosemide does not have any analgesic effects, and pain may be caused by various conditions that are not related to fluid volume excess.

Normal ranges for weight, blood pressure and pain vary depending on the individual patient’s baseline and goals.

However, some general guidelines are:

Weight: A weight loss of 0.5 to 1 kg per day is considered safe and effective for patients with fluid volume excess.
Blood pressure: The target blood pressure for most patients with heart failure is less than 130/80 mmHg.
Pain: The pain level should be assessed using a valid and reliable scale, such as the numeric rating scale or the visual analogue scale, and treated according to the patient’s preference and tolerance.

A. Heart rate. B. Current medications. C. Blood pressure. D. Stool results. E. Respiratory rate. F. WBC count. G. Temperature. H. Hemoglobin and hematocrit.

Correct Answer is ["A","B","C","D","H"]

Explanation

A, B, C, D, and H. Here is why:.

A. Heart rate: The client’s heart rate is elevated at 118/min, which could indicate blood loss, dehydration, pain, anxiety, or infection. This finding requires immediate follow-up to assess the cause and intervene as needed.
B. Current medications: The client is taking ibuprofen 800 mg three times daily PRN for arthritis pain. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastric irritation, ulceration, and bleeding. This finding requires immediate follow-up to evaluate the client’s pain level, medication use, and possible alternatives to NSAIDs.
C. Blood pressure: The client’s blood pressure is low at 90/50 mm Hg, which could indicate hypovolemia, shock, or cardiac dysfunction. This finding requires immediate follow-up to monitor the client’s fluid status, perfusion, and organ function.
D. Stool results: The client’s stool tested positive for occult blood and H. pylori bacteria. Occult blood indicates gastrointestinal bleeding, which could be related to the client’s abdominal pain and weight loss. H. pylori is a common cause of peptic ulcer disease, which can also cause bleeding and pain. This finding requires immediate follow-up to confirm the diagnosis and initiate treatment with antibiotics and acid-suppressing drugs.

H. Hemoglobin and hematocrit: The client’s hemoglobin and hematocrit are low at 9.1 g/dL and 27%, respectively. These values indicate anemia, which could be caused by chronic blood loss, nutritional deficiency, or bone marrow suppression. This finding requires immediate follow-up to determine the etiology and severity of the anemia and provide appropriate therapy such as blood transfusion, iron supplementation, or erythropoietin.

The other findings are not as urgent as the ones above:.

E. Respiratory rate: The client’s respiratory rate is normal at 18/min. There is no evidence of respiratory distress or hypoxia.
F. WBC count: The client’s WBC count is normal at 6,700/mm3. There is no indication of infection or inflammation.
G. Temperature: The client’s temperature is slightly elevated at 37.5° C (99.5° F), but not enough to warrant immediate concern. It could be due to stress, dehydration, or a mild infection. The nurse should monitor the temperature trend and report any significant changes or signs of sepsis.

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A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

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A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

Correct Answer is A

Explanation

A nurse is caring for a client who is admitted to the medical-surgical unit. Client reports, "I'm bloated and my stomach hurts." Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","D","H"]

Explanation

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A nurse manager is updating protocols for the use of belt restraints.

Which of the following guidelines should the nurse manager include?