A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?

Release the client's restraints every 4 hr.

Check the client's status every hour.

Document the client's behavior leading to the initiation of the restraints.

Obtain written consent by the client for the placement of the restraints.

Release the client's restraints every 4 hr.

Check the client's status every hour.

Document the client's behavior leading to the initiation of the restraints.

Obtain written consent by the client for the placement of the restraints.

Answer and Explanation

The Correct Answer is C

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

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Correct Answer is ["C"]

Explanation

A. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma.The opening on the skin barrier should be cut to fit closely around the stoma, approximately 0.3-0.6 cm (1/8 to 1/4 inch) larger than the stoma size. A larger opening (like 0.5 inches) could expose too much surrounding skin, increasing the risk of skin irritation from contact with the stoma's effluent.

B. Use a moisturizing soap to clean the skin around the client's stoma.Moisturizing soaps should be avoided because they can leave a residue on the skin, which may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with mild soap and water, or water alone, and then dried thoroughly before applying the new appliance.

C. Empty the client's ostomy pouch before removing the skin barrier.Emptying the ostomy pouch before removing the skin barrier is a practical step to reduce spillage of stool during the appliance change, making the process cleaner and easier to manage. It also minimizes the risk of contamination of the surrounding area or wound.

D. Change the client's ostomy appliance 1 hour after breakfast.Ostomy appliances are best changed when the bowel is least active, which is usually before a meal or several hours after eating. Changing the appliance shortly after a meal, such as 1 hour after breakfast, may result in more stoma output, making it harder to manage the appliance change.

A. Remove the tape by pulling from the center of the dressing B. Wear sterile gloves to remove the dressing C. Clean the wound from the center to the outer edges D. Moisten the dressing before removal

Correct Answer is C

Explanation

When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.

The other options listed are not recommended for this specific procedure:

When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.

While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.

In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is ["C"]

Explanation

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

Correct Answer is C

Explanation

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