Try Naxlex NCLEX-RN (Free-Trial)

The nurse plans care for a client who requires physical restraints. Which actions should the nurse include in the plan? Select all that apply.

Place the client in an area where they can be supervised.

Release the restraints every 2 hours for turning repositioning, and toileting

Turn the television on if the client is agitated.

Provide soft, calming music.

Cover tubes and lines with roller gauze if the client pulls at them

Encourage family members to go home at night.

Regularly determine the need to continue using restraints

Answer and Explanation

Correct Answer : A,B,D,G

Physical restraints are behavioral and safety interventions used in clients with severe agitation risk, impaired cognitive control, or danger to self/others. They require strict adherence to least restrictive measures, continuous circulatory monitoring, and frequent reassessment to prevent complications such as pressure injury, hypoxia, and psychological distress.

Rationale:

A. Clients in restraints must be placed in areas allowing continuous direct observation to prevent injury, entanglement, or circulatory compromise. This ensures rapid intervention if agitation or respiratory distress occurs. Supervision is a core safety requirement in restraint management protocols.

B. Restraints must be released at least every 2 hours to allow skin integrity assessment, range of motion, and elimination needs. This prevents neurovascular impairment, pressure injuries, and contractures. Scheduled release is a mandatory safety standard in restraint care.

C. Increasing stimulation with television may worsen sensory overload and agitation in restrained clients. This can escalate behavioral dysregulation rather than promote calming. It is not an appropriate intervention for restraint-associated anxiety management or behavioral control.

D. Soft, calming music reduces sympathetic nervous system activation and promotes relaxation in agitated clients. It supports de-escalation and decreases reliance on restraints. This is an appropriate non-pharmacologic intervention to reduce agitation and improve emotional regulation.

E. Covering tubes with gauze does not address underlying behavioral safety risk and may delay identification of complications such as dislodgement or obstruction. It is not a standard restraint alternative or safety intervention in clinical guidelines.

F. Encouraging family to leave reduces therapeutic support presence, which may worsen anxiety and agitation. Family involvement can provide reassurance and orientation. Removing support is not appropriate unless clinically indicated for safety reasons.

G. The need for continued restraints must be reassessed regularly to ensure least restrictive intervention is maintained. Ongoing evaluation prevents unnecessary restraint use and reduces risk of complications. This is a legal and ethical requirement in restraint management protocols.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Cost-effective wound care management requires integration of resource allocation, budget control, supply utilization, and financial planning to ensure clinical effectiveness while minimizing waste, optimizing dressing selection, and maintaining evidence-based wound healing standards across healthcare delivery systems.

Rationale:

A. This action demonstrates financial planning and resource allocation essential for cost-effective wound care management. Developing a budget spreadsheet allows tracking of supply usage, expenditure patterns, and waste reduction. It directly supports efficient procurement and sustainable wound care delivery systems.

B. This action reflects professional education and staff development, improving clinical knowledge through teleconferenced conferences. However, it does not directly address cost containment or resource utilization. It may improve care quality but lacks direct financial management or cost-effectiveness planning focus.

C. This action promotes evidence-based practice through literature review, enhancing nursing knowledge in wound care advancements. While beneficial for clinical competence, it does not directly influence budgeting, supply costs, or financial efficiency in wound care delivery systems.

D. This action involves clinical education focused on infection recognition, improving early identification of wound complications. However, it does not address financial planning or resource optimization. It supports clinical outcomes but lacks direct cost-effective management strategies for wound care systems.

A. Gives staff freedom to make decisions B. Expects staff to solve problems on their own C. Uses rewards or punishments to encourage compliance D. is ultimately responsible for the decisions made by staff members E. Strictly enforces rules to maintain compliance

Correct Answer is ["A","B","D"]

Explanation

Laissez-faire leadership characterizes a permissive environment where minimal guidance is provided to subordinates. This style relies on individual autonomy and the professional maturity of staff, often proving effective in highly specialized units where practitioners possess advanced expertise and self-direction.

Rationale:

A. Laissez-faire leaders provide maximal autonomy, allowing experienced staff to exercise their own clinical judgment. Giving staff the freedom to make decisions encourages self-reliance and can lead to increased job satisfaction among highly skilled professionals.

B. This leadership style assumes that staff possess the requisite competence to navigate clinical challenges independently. By expecting members to solve problems, the leader avoids micro-management, though this can lead to disorganization if the team lacks direction.

C. Using contingent rewards or punishments is a hallmark of transactional leadership, not laissez-faire. Laissez-faire leaders generally remain passive, avoiding active intervention or the structured enforcement of extrinsic motivators to drive performance.

D. Despite the hands-off approach, the leader retains legal accountability for the unit's outcomes. Being ultimately responsible means the leader must still monitor safety and quality, even while delegating the decision-making process to the team.

E. Strict rule enforcement is characteristic of autocratic or bureaucratic leadership styles. Laissez-faire leaders avoid regulatory rigidity, instead fostering a loose structure that may lack the consistency required for maintaining rigorous organizational compliance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse plans care for a client who requires physical restraints. Which actions should the nurse include in the plan? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is a member of the resource management team for a skilled care facility. Which action should the charge nurse take to ensure the facility provides cost-effective wound care for clients?

Correct Answer is A

Explanation

A nurse is planning to teach a class on the laissez-faire leadership style. The nurse should include which characteristics of laissez-faire leaders? Select All That Apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is participating on a quality improvement (QI) committee that is tasked with developing a program to reduce medication administration errors following a sentinel event at the facility. Which action should the committee take first?

A charge nurse on a medical-surgical unit has just been notified that the disaster protocol is being implemented following a natural disaster. Which action should the nurse take?

The community health nurse is triaging victims at the disaster site. Which client should the nurse categorize as a black tag?

A nurse is caring for a client who has pneumonia. Which tool should the nurse use to assist with providing cost-effective care?

The nurse cares for four clients on the medical-surgical unit. Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select All That Apply.

The registered nurse in charge on the cardiac unit must float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department?