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 D
Explanation
Diminished breath sounds in a client admitted with pneumonia. This is because diminished breath sounds indicate a worsening of the respiratory condition and a possible complication of pneumonia, such as atelectasis or pleural effusion.
The healthcare provider should be notified immediately to assess the client and order appropriate interventions.
Choice A is wrong because a report of joint pain by a client who recently started taking arthritis medication is not an urgent finding.
Joint pain is a common symptom of arthritis and may take some time to improve with medication.
The nurse should monitor the client’s pain level and administer analgesics as prescribed.
Choice B is wrong because report of decreased appetite and difficulty sleeping is not an immediate concern.
These are nonspecific symptoms that may be related to stress, anxiety, depression, or other factors.
The nurse should explore the possible causes of these symptoms and provide emotional support and education to the client.
Choice C is wrong because a weight loss of two pounds in a client admitted to congestive heart failure is not a critical finding.
Weight loss may indicate a reduction of fluid retention, which is a desired outcome for clients with heart failure.
The nurse should monitor the client’s weight daily and report any significant changes to the health care provider.
Normal ranges for weight, appetite, sleep, joint pain, and breath sounds vary depending on the individual’s age, gender, height, activity level, medical history, and other factors.
Correct Answer is B
Explanation
Notify the health care provider. The nurse should take this action first because the provider can prescribe appropriate interventions to prevent or minimize harm to the client.
The nurse should also inform the unit supervisor, document the error in the client’s medical record, and record the error on the appropriate quality improvement report, but these are not the priority actions.
Choice A is wrong because informing the unit supervisor is not the most urgent action. The supervisor can provide support and guidance to the nurse, but cannot prescribe interventions for the client.
Choice C is wrong because documenting the error in the client’s medical record is not the most urgent action.
The nurse should document the error after notifying the provider and assessing the client. Documentation should include the medication name, dose, route, time, client’s response, and actions taken.
Choice D is wrong because recording the error on the appropriate quality improvement report is not the most urgent action.
The nurse should record the error after notifying the provider and assessing the client. The report should include a factual description of what happened and what was done.
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