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. Before administering a cleansing enema, the client is typically instructed to assume a left-side lying position with the right knee bent. This position helps to facilitate the flow of the enema solution into the colon and allows for better retention of the solution. It also helps to prevent leakage and discomfort during the procedure.

A. Drinking water before administering an enema can help hydrate the client and promote normal bowel function. However, it is not typically a specific instruction related to the administration of the enema itself. Hydration is generally beneficial for bowel health but is not directly related to the enema procedure.

B. After administering the enema solution, the client should be instructed to hold the solution in the bowel for a sufficient amount of time to allow it to soften and loosen stool. The exact duration can vary based on the type and purpose of the enema, but typically, the client is encouraged to retain the solution for a specified period (as instructed by the healthcare provider) before evacuating.

C. This instruction is unrelated to the administration of a cleansing enema. Breathing techniques may be taught for relaxation or to manage discomfort during procedures, but they do not specifically apply to the process of administering an enema.

A. Ineffective Sexuality Pattern B. Risk for Social Isolation C. Activity Intolerance D. Imbalanced Nutrition: less than body requirements

Correct Answer is D

Explanation

D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.

A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.

C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.

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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 client is prescribed a cleansing enema. Prior to administering the enema, the client should be told to:

Correct Answer is D

Explanation

The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?

Correct Answer is D

Explanation

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