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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Free Nursing Study Resources

Correct Answer is C

Explanation

Wearing a medical identification wristband is important for children with chronic conditions such as cystic fibrosis. It helps alert others, including healthcare providers, about the child's condition in case of emergencies. The wristband can provide vital information about the child's diagnosis, treatment needs, and emergency contacts, ensuring appropriate care and timely interventions.

The other options mentioned are not appropriate or necessary for the care of a child with cystic fibrosis:

A- It is important to involve the child to an age-appropriate extent in decision-making about their treatment. Encouraging the child to participate in their own care and treatment decisions can promote their independence and self-management skills.

B- The influenza vaccine is generally recommended for children with cystic fibrosis, as they are at increased risk of respiratory infections. The vaccine helps protect against influenza and its potential complications. Therefore, the nurse should emphasize the importance of annual influenza vaccination for the child.

D- Homeschooling may not be necessary solely based on the diagnosis of cystic fibrosis. The decision regarding the child's education should be made based on their individual needs, abilities, and preferences, in consultation with the child's healthcare team and educational professionals.

A. Time B. Medication C. Dosage D. Route

Correct Answer is D

Explanation

A.The prescription specifies “four times per day,” which is clear.

B.The medication specified is erythromycin, which is clear

C.The dosage of 500 mg is clearly specified.

D.The route of administration eg. oral, topical is not specified and needs to be clarified to ensure proper administration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

Correct Answer is D

Explanation

A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should include that which of the following is an acceptable weight gain for this client?

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching?

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?