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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.
The other choices are wrong because:
Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.
Choice C. “Don’t think like that.
It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.
Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.
Correct Answer is A
Explanation
“I will discard unused pills after six months after replacing it with a new vial.” This statement indicates that the client understands that nitroglycerin tablets lose their potency over time and need to be replaced regularly.
Choice B is wrong because nitroglycerin can cause headaches as a side effect, but the client should not stop taking it if they have chest pain. They can use Tylenol for pain relief.
Choice C is wrong because nitroglycerin can cause hypotension and dizziness, so the client should avoid lying down or changing positions suddenly after taking it. They should sit or stand still until the chest pain subsides.
Choice D is wrong because a tingling feeling on the tongue is a normal sensation when taking sublingual nitroglycerin and does not indicate an adverse reaction. It also confirms that the tablet is potent and effective.
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