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

Request a PRN restraint prescription for clients who are aggressive.

Document the client's condition every 15 min.

Attach the restraint to the bed's side rails.

Remove the client's restraint every 4 hr.

Answer and Explanation

The Correct Answer is B

Answer is: b. Document the client's condition every 15 min.

Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.

Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.

Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.

Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.

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Correct Answer is C

Explanation

Choice A rationale:

Heart rate 58/min. Clozapine, an atypical antipsychotic medication, can cause bradycardia (slow heart rate) as a side effect. However, the heart rate of 58/min is within the normal range for adults, so it is not a contraindication for clozapine administration.

Choice B rationale:

Fasting blood glucose 100 mg/dL. A fasting blood glucose level of 100 mg/dL is within the normal range (70-99 mg/dL) for adults. It is not a contraindication for clozapine administration.

Choice C rationale:

WBC count 2,900/mm3. Clozapine can cause agranulocytosis, a severe reduction in white blood cell (WBC) count, which can lead to increased susceptibility to infections. A WBC count of 2,900/mm3 is significantly below the normal range (4,000-11,000/mm3) and is a contraindication for clozapine administration due to the risk of severe immunosuppression.

Choice D rationale:

Hgb 14 g/dL. Hemoglobin (Hgb) level of 14 g/dL is within the normal range for adult males (13.8-17.2 g/dL) and females (12.1-15.1 g/dL). It is not a contraindication for clozapine administration.

A. Include any adverse effects of the medications the client might develop. B. Compare new prescriptions with the list of medications the client reports. C. Exclude nutritional supplements from the list of medications the client reports. D. Encourage the client to make his own list after he returns to his home.

Correct Answer is B

Explanation

Choice A rationale:

Including any adverse effects of the medications the client might develop is important but does not cover the entire scope of medication reconciliation. It is essential to compare new prescriptions with the list of current medications to prevent drug interactions, duplications, or omissions.

Choice B rationale:

Comparing new prescriptions with the list of medications the client reports is the correct approach to medication reconciliation. This helps identify discrepancies, ensuring that the client's current medications are accurately documented and preventing medication errors.

Choice C rationale:

Excluding nutritional supplements from the list of medications the client reports is incorrect. Nutritional supplements, herbal remedies, and over-the-counter medications are essential components of the medication list. These items can interact with prescribed medications and affect the client's overall health.

Choice D rationale:

Encouraging the client to make his own list after he returns home is not recommended. Patients might not have complete knowledge of the medications they are taking, including dosages and frequencies. Relying solely on the patient-generated list can lead to inaccuracies and potential harm.

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