Nurse observed client attempting to pull out IV line and urinary catheter. Attempts made to reorient and calm client are unsuccessful. Instructed assistant personnel to stay with client. Placed call to provider and family. Return call from provider, update given. Prescription received for soft wrist restraints. Please complete the sentence based off of your understanding of restraints.
Complete the following sentence by using the list of options.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Rationale for correct answers:
a) Apply soft wrist restraints with assistance:
The nurse has already received a prescription from the provider for restraints due to the client actively attempting to remove medical devices. This makes the restraint medically justified and legally authorized. The restraints should be applied safely and with assistance to prevent injury during application.
c) Document the restraint application, reason, and patient response in the record:
Documentation is a legal and professional responsibility. It ensures the rationale, time, condition, interventions attempted before restraints, and client response are recorded clearly.
Rationale for incorrect answers:
b) Administer pain medication for agitation:
No indication in the note suggests pain as the cause of agitation. Medication without cause or order for agitation is inappropriate.
c) Notify the family of the restraint application:
While notifying the family is appropriate and often done, it is not the first or immediate priority once the restraint order is in place and the client is at risk of self-harm.
a) Notify charge nurse and ask for sitter assignment:
This is a helpful support measure, but after applying the restraints and documenting the care. It does not take precedence over immediate client safety and legal documentation.
b) Remove the catheter and IV to prevent further injury:
This would violate the standard of care unless ordered by the provider. The correct action is to prevent removal by using restraints safely and legally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: It is typically defined by a drop of ≥10 mm Hg diastolic or ≥20 mm Hg systolic.
B. Orthostatic hypotension increases a client's risk of a pulmonary emboli: Orthostatic hypotension does not cause PE; they are unrelated pathophysiologies.
C. Orthostatic hypotension increases a client's risk of a fall: The drop in blood pressure on standing can cause dizziness or fainting, leading to a fall risk.
D. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: The correct threshold is ≥20 mm Hg systolic.
Correct Answer is C
Explanation
A. "I'll carry objects close to my body.": Carrying objects close to the center of gravity reduces strain on the back.
B. “I'll do exercises that strengthen my abdominal muscles.": Strong core muscles support the spine and prevent injury.
C. "When standing for a long period of time. I should keep my feet flat on the floor.": This statement indicates a need for further instruction. One foot should be slightly elevated on a footrest or step to reduce lumbar strain.
D. "I'll wear low-heeled shoes from now on.": Low-heeled shoes provide better spinal alignment and reduce back stress.
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