A nurse who has returned to nursing after a 5-year break applies wrist restraints to a combative patient. Which action indicates that this nurse needs further education?

The nurse checks on the patient every 25 minutes to verify they are safe.

The nurse inserts two fingers underneath the restraint to check for appropriate tightness.

The nurse obtains an order from the provider prior to applying restraints.

The nurse releases the restraints every two hours for range of motion and patient needs.

Answer and Explanation

The Correct Answer is A

Choice A reason: This action indicates the nurse needs further education because safety checks for patients in restraints must occur at least every 15 minutes in most acute care settings, or per facility policy, not every 25 minutes. The purpose of frequent monitoring is to ensure circulation, skin integrity, and patient safety. Extending the interval to 25 minutes increases the risk of complications such as impaired circulation, injury, or psychological distress. This demonstrates a lack of updated knowledge on restraint protocols.

Choice B reason: This action is correct because inserting two fingers under the restraint ensures that it is applied with appropriate tightness. Restraints should be snug enough to prevent removal but loose enough to allow circulation and prevent nerve damage. This practice reflects proper technique and patient safety awareness.

Choice C reason: This action is correct because restraints must always be ordered by a licensed provider before application, except in emergencies where immediate safety is at risk. Obtaining an order demonstrates adherence to legal and ethical standards, as restraints are considered a last resort intervention.

Choice D reason: This action is correct because restraints must be released at least every two hours to allow for range of motion, repositioning, toileting, and other patient needs. This prevents complications such as contractures, pressure injuries, and emotional distress. It also ensures the patient’s dignity and comfort are maintained.

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Correct Answer is B

Explanation

Choice A reason: This method is imprecise and does not ensure accurate placement. Moving the stethoscope randomly until a heartbeat is detected may lead to incorrect readings, especially in patients on cardiac medications like Digoxin, where accuracy is critical.

Choice B reason: This is the correct method. The apical pulse is best assessed at the 5th intercostal space, mid-clavicular line, using a stethoscope for a full 60 seconds. This ensures accuracy, especially when monitoring for arrhythmias or bradycardia, which are potential side effects of Digoxin.

Choice C reason: This method is incorrect because auscultating for only 30 seconds and multiplying by 2 may miss irregular rhythms. Digoxin can cause bradycardia and arrhythmias, so a full 60-second count is necessary to detect abnormalities.

Choice D reason: This location is incorrect. The 3rd intercostal space, mid-axillary line does not correspond to the apical pulse site. Using the wrong anatomical landmark would result in inaccurate assessment.

A. I observed the patient fall on the floor. B. Vital signs are BP 120/80, pulse 72, respirations 16. C. The patient is a 70-year-old male, diagnosed with dementia. D. I recommend an order for a culture and sensitivity (C&S) to confirm an infection.

Correct Answer is D

Explanation

Choice A reason: This statement reflects the “Situation” portion of SBAR, where the nurse describes the immediate issue or event. It does not represent the “Recommendation” section.

Choice B reason: This statement reflects the “Assessment” portion of SBAR, where objective data such as vital signs are communicated. It is not the “Recommendation.”

Choice C reason: This statement reflects the “Background” portion of SBAR, where patient history and relevant information are provided. It does not represent the “Recommendation.”

Choice D reason: This is the correct statement because the “Recommendation” portion of SBAR involves suggesting actions or interventions to address the patient’s condition. Recommending a culture and sensitivity test is an appropriate example of a recommendation.

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A nurse who has returned to nursing after a 5-year break applies wrist restraints to a combative patient. Which action indicates that this nurse needs further education?

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Naxlex Comprehensive Predictor Exams

The nurse needs to verify the apical pulse rate of his patient who takes Digoxin (cardiac medication). Which of the following is the best way to find an apical heart rate?

Correct Answer is B

Explanation

The nurse is aware that the first “R” in I-SBAR reflects which statement best?

Correct Answer is D

Explanation

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