Medicare and The Joint Commission have identified which criteria that nurses must consider when using patient restraints? (SELECT ALL THAT PPLY)

Only punitive measures work

Physician's order required

All less restrictive approaches have been tried

Inadequate staffing

Remove restraints every 8 hours

Answer and Explanation

Correct Answer : B,C,E

B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.

C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.

E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.

A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.

D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.

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Correct Answer is ["C","D","E"]

Explanation

C. Rapid heart rate (tachycardia) can be a sign of fluid overload, as the heart compensates for increased volume by beating faster to maintain cardiac output.

D. Shortness of breath (dyspnea) can indicate fluid overload, especially if it is new or worsening and associated with pulmonary congestion due to fluid accumulation.

E Elevated blood pressure can be a sign of fluid overload, as increased circulating volume can lead to hypertension.

A. This statement suggests a decrease in peripheral edema, which is a positive sign and does not typically indicate fluid overload. It may actually indicate improvement.

B. Dizziness can be a symptom of hypovolemia (low fluid volume) rather than fluid overload. It is not typically a specific sign of fluid overload.

A. Administration of an enema B. Administration of an intramuscular injection C. Insertion of a nasogastric tube D. Insertion of an indwelling catheter

Correct Answer is D

Explanation

D. Inserting an indwelling catheter involves placing a tube into the bladder through the urethra. The urethra and urinary tract are sterile areas. Sterile gloves are necessary to prevent introducing pathogens into the urinary tract during catheter insertion.

A. An enema involves introducing a solution into the rectum for therapeutic purposes. It does not require the use of sterile gloves because the rectum and lower gastrointestinal tract are not considered sterile areas.

B. Administering an intramuscular injection involves injecting medication into muscle tissue. It does not require sterile gloves unless the site needs to be cleaned with an antiseptic wipe, in which case non- sterile gloves are sufficient.

C. The insertion of a nasogastric tube also does not typically require sterile gloves, as the gastrointestinal tract is not a sterile environment.

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Medicare and The Joint Commission have identified which criteria that nurses must consider when using patient restraints? (SELECT ALL THAT PPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

The nurse is caring for hospitalized clients. Which nursing action requires the nurse to use sterile gloves?

Correct Answer is D

Explanation

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