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

The correct answer is c. Use an albuterol inhaler.

Choice A reason: Eating a meal before postural drainage is not recommended because it can cause discomfort, nausea, or vomiting due to the positions required for the procedure.

Choice B reason: Taking pancrelipase is important for aiding digestion in cystic fibrosis patients, but it is not specifically related to the preparation for postural drainage.

Choice C reason: Bronchodilators like albuterol are used before airway clearance techniques to open the airways, making it easier to clear mucus during postural drainage.

Choice D reason: While maintaining oral hygiene is important for overall health, it is not a preparation step for postural drainage.

A. Recent myocardial infarction. B. Recent eye surgery. C. Thrombophlebitis. D. Breast cancer.

Correct Answer is B

Explanation

Choice A rationale:

Recent myocardial infarction is not a contraindication for warfarin administration. Warfarin is often prescribed for patients with a history of myocardial infarction to prevent clot formation and reduce the risk of stroke.

Choice B rationale:

Recent eye surgery is a contraindication for the administration of warfarin. Warfarin can increase the risk of bleeding, which is particularly concerning after eye surgery due to the delicate nature of ocular tissues. Using anticoagulants in this scenario can lead to severe complications, including vision loss.

Choice C rationale:

Thrombophlebitis, inflammation of a vein with clot formation, is not a contraindication for warfarin administration. In fact, anticoagulants like warfarin are commonly prescribed to prevent the extension of clots and reduce the risk of complications associated with thrombophlebitis.

Choice D rationale:

Breast cancer is not a direct contraindication for warfarin administration. However, the decision to use anticoagulants in patients with a history of breast cancer should be made carefully, considering individual factors such as the stage of cancer, ongoing treatment, and overall risk of thromboembolic events.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

Correct Answer is C

Explanation

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Correct Answer is B

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?