Which nursing intervention should be performed before applying client restraints?

Visual inspection of skin for placement.

Positioning for proper body alignment.

Assess the need for restraints placement.

Review facility policy before usage.

Answer and Explanation

The Correct Answer is C

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

These are natural respiratory defense mechanisms that help defend against infection.

Choice A is correct because cilia lining the respiratory tract sweep debris upward in mucus to be swallowed.

This prevents pathogens and particles from reaching the lungs.

Choice B is wrong because the respiratory tract does not cool and dry the air being inhaled. In fact, the respiratory tract warms and humidifies the air to facilitate gas exchange.

Choice C is correct because cells in the respiratory tract secrete lysozymes that can destroy certain bacteria.

Lysozymes are enzymes that break down the cell walls of bacteria.

Choice D is correct because macrophages engulf and destroy bacteria found in the alveoli. Macrophages are a type of white blood cell that act as scavengers of foreign invaders.

Choice E is wrong because high concentrations of oxygen and carbon dioxide do not aid the defense mechanisms.

On the contrary, high levels of these gases can impair gas exchange and cause acid-base imbalance.

A. “I don’t know because I am off duty now and I think you need to ask the nurse coming on this shift.”. B. “That is privileged, confidential information and I can’t discuss it with you now.”. C. “Why don’t we step off the elevator to discuss this in a more private area?”. D. “The client was stable before I left 30 minutes ago, but had to be restrained for agitation.”.

Correct Answer is C

Explanation

The nurse should respect the client’s privacy and confidentiality by not discussing the client’s condition in a crowded elevator, even with the health care provider. The nurse should suggest a more private area to have the conversation.

Choice A is wrong because it shows a lack of professionalism and accountability. The nurse should be able to provide a brief update on the client’s status to the health care provider, even if the nurse is off duty.

Choice B is wrong because it implies that the healthcare provider does not have the right to access the client’s information, which is not true. The health care provider is part of the health care team and has a legitimate need to know the client’s condition.

Choice D is wrong because it violates the client’s privacy and confidentiality by disclosing sensitive information in front of other people. The nurse should not share any details about the client’s condition or treatment without the client’s consent or unless it is necessary for the client’s care.

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

Which nursing intervention should be performed before applying client restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client at risk for a respiratory infection. Which of the following natural respiratory defense mechanisms help defend against infection? (Select all that apply).

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

Explanation

At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider. Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.

Correct Answer is C

Explanation

A client is to receive medications that are highly teratogenic. What question should the nurse ask the client to support safe medication administration?

Which client behavior is indicative of hearing loss?

A client is diagnosed with hepatitis. C.Which client risk factor would be most related to this diagnosis?

A client in the clinic states, “I already told you I can’t come back on Friday.” Which response by a nurse would be likely to repair the client-nurse relationship?

What is the best question to evaluate a client’s understanding of infection control measures while receiving treatment for hepatitis A?

A client has been treated for hypertension. What blood pressure reading indicates to the nurse that the treatment is effective?

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?