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 D

Explanation

D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable

A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.

B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.

C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.

A. listens as the client describes the day she was diagnosed with breast cancer. B. compliments the client when he correctly places an ostomy bag on his stoma. C. provides a bed bath with a back rub to help the client relax. D. maintains eye contact with the client throughout their conversation.

Correct Answer is A

Explanation

A. By actively listening, the nurse shows empathy and a willingness to understand the client's perspective. Understanding significant events like a cancer diagnosis can help the nurse better anticipate the client's emotional and psychological needs.

B. This action shows support and encouragement for the client's achievements in managing their condition. It demonstrates the nurse's awareness of the client's efforts and competence in self-care. While it is positive reinforcement and supportive, it focuses more on the client's physical abilities rather than a deeper understanding of their personal experiences or emotions.

C. This action shows attentiveness to the client's physical comfort and emotional well-being. Offering a back rub during a bed bath can be soothing and comforting, addressing both physical and emotional needs. It demonstrates a caring approach to providing care that considers the client's comfort and relaxation.

D. Eye contact is an important non-verbal communication skill that conveys attentiveness and respect. It helps establish a connection and rapport between the nurse and the client. While maintaining eye contact is important for effective communication and building trust, it alone does not necessarily illustrate knowing the client in terms of understanding their personal experiences or emotions.

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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

The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

Correct Answer is D

Explanation

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

Correct Answer is A

Explanation

The nurse reviews the list of medications that will be administered through a client's new gastrostomy tube. All medications were previously given PO. Which medication order will the nurse question?

A nurse educator is teaching student nurses about droplet precautions. The educator emphasizes the differences between indications for droplet precautions versus airborne precautions. Which of the following statements about droplet precautions are correct? (SELECT ALL THAT APPLY)

A client is brought into the emergency department for an overdose of morphine. The client has a respiratory rate of 5 to 8 breaths per minute. Which of the following ABG results would the nurse expect to see?

Which goal is appropriate for a client who is experiencing diarrhea? The client will:

The nurse recognizes that the client's energy has been depleted despite attempts to intervene and the client dies. This is a description of which phase of the General Adaptation Syndrome?

The nurse is caring for a client who is having difficulty sleeping in the hospital environment. How can the nurse intervene? (SELECT ALL THAT APPLY)

It is important for the nurse to ensure that the client's post-operative Jackson-Pratt device is patent because its purpose is to:

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