The Licensed Practical Nurse (LPN) will anticipate that the patient with restraints will need which additional care?
Remove the restraints every 15 minutes and offer to toilet the client
Check the restraints every 2 hours to be sure they are properly applied
Have the UAP (unlicensed assistive personnel) assess every hour for safety
Check the patient every 15 minutes and remove the restraints every 2 hours, if safe
The Correct Answer is D
Choice A reason: Removing restraints every 15 minutes is excessive and impractical. While frequent monitoring is required, removing restraints this often could compromise patient safety if the restraints are necessary to prevent harm. Toileting should be offered regularly, but the removal schedule must balance patient dignity with safety.
Choice B reason: Checking restraints every 2 hours is insufficient. Patients in restraints must be monitored much more frequently to ensure circulation, skin integrity, and safety. Two-hour intervals could allow complications such as impaired circulation, skin breakdown, or psychological distress to go unnoticed.
Choice C reason: Delegating safety checks to a UAP every hour is inappropriate because restraint monitoring requires licensed nursing judgment. LPNs must personally assess circulation, skin condition, and patient comfort. UAPs can assist with care but cannot replace the nurse’s responsibility for restraint monitoring.
Choice D reason: The correct action is to check the patient every 15 minutes and remove restraints every 2 hours if safe. This schedule ensures frequent monitoring for circulation, skin integrity, and psychological well-being, while also providing opportunities for mobility, toileting, and comfort. Removing restraints every 2 hours prevents complications and respects patient dignity, while frequent checks ensure safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Medication errors are a major patient safety risk in healthcare facilities. They can occur during prescribing, dispensing, or administration and may result in adverse drug events, prolonged hospitalization, or even death.
Choice B reason: Falling off a ladder is not a typical patient safety risk within a healthcare facility. Patients are not expected to use ladders in clinical settings, so this option is irrelevant.
Choice C reason: Pressure ulcers are a significant risk, especially for immobile or critically ill patients. They result from prolonged pressure on the skin and can lead to infection, pain, and increased length of stay. Preventive measures such as repositioning and skin care are essential.
Choice D reason: Falling out of bed is a common safety risk, particularly for elderly or confused patients. Falls can cause fractures, head injuries, and other complications, making fall prevention a priority in healthcare facilities.
Choice E reason: Latex reactions are a recognized safety risk, especially for patients with latex allergies. Exposure can cause mild skin irritation or severe anaphylaxis. Facilities must use latex-free products for sensitive patients.
Correct Answer is A
Explanation
Choice A reason: The patient with a respiratory rate of 20 and a temperature of 100.5 °F shows early signs of a possible infection or respiratory compromise. While the vital signs are only mildly abnormal, an elevated temperature in combination with respiratory changes can indicate a developing systemic issue that requires close monitoring. In adult patients, a temperature above 100.4 °F is considered a fever and warrants assessment for infection or other underlying conditions.
Choice B reason: A pulse of 90 is within normal adult limits (60–100 bpm) and, in the absence of other symptoms, does not indicate an urgent concern. Although slightly elevated, it can be a normal physiologic response to mild stress, activity, or anxiety.
Choice C reason: A blood pressure of 116/72 mmHg is within the normal range for adults and does not require immediate concern. It indicates adequate perfusion and cardiovascular stability.
Choice D reason: A respiratory rate of 12 and a temperature of 98.6 °F are within normal adult ranges, indicating no acute respiratory or infectious issues. This patient would not be a priority concern at this time.
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