Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

A family member expresses concern about their relative "picking" at the nasal gastric tube (NG) tube.

A client is walking the halls at night rubbing his hands together.

A 16-year-old boy swung his fist at the nurse.

A disoriented client removed the mesh wrapped intravenous (IV) line for the second time.

Answer and Explanation

The Correct Answer is D

Rationale:

A. A family member expresses concern about their relative "picking" at the nasogastric (NG) tube: Family concern should be acknowledged, but restraint use must be based on clinical necessity. The nurse can first implement non-restrictive interventions before considering restraints.

B. A client is walking the halls at night rubbing his hands together: This behavior does not indicate harm to self or others or interference with medical devices. There is no justification for restraint, and doing so could violate patient rights and ethical standards.

C. A 16-year-old boy swung his fist at the nurse: This may call for emergency behavioral restraints rather than mitten restraints. If the behavior poses a threat of violence, other forms of crisis intervention or behavioral management should be pursued first.

D. A disoriented client removed the mesh-wrapped intravenous (IV) line for the second time: Mitten restraints may be considered when a client repeatedly removes critical lines or tubes, especially when cognitively impaired. This situation meets the clinical indication for discussing their use with the provider to prevent treatment disruption while ensuring safety.

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Correct Answer is C

Explanation

Rationale:
A. Teach parents about poison prevention in young children: While this is an important long-term intervention, it does not address the immediate concern of replacing a potentially lost therapeutic dose of the antidote. Teaching should occur after the child’s safety is ensured.

B. Lavage activated charcoal before giving acetylcysteine dose: Activated charcoal may reduce acetylcysteine’s effectiveness when administered together. Gastric lavage is not routinely indicated if the child is alert and beyond the immediate ingestion window, and is not a substitute for re-dosing the antidote.

C. If dose is vomited within 1 hour of administration, repeat that oral dose: Re-administering N-acetylcysteine within one hour of vomiting ensures the child receives an effective therapeutic dose. Prompt re-dosing is crucial in preventing hepatic damage.

D. Obtain blood samples to monitor liver function: Liver function tests are part of ongoing monitoring but do not address the acute need to ensure the antidote is absorbed. Blood work is secondary to ensuring that the child receives the full therapeutic dose.

A. A bucket of water was spilled in the hallway. B. One staff member has not reported to work. C. A client's wife has asked to speak with the charge nurse. D. The census report has not been completed.

Correct Answer is A

Explanation

Rationale:

A. A bucket of water was spilled in the hallway: This represents an immediate safety hazard for staff, clients, and visitors. Wet floors can lead to serious falls and injuries, so it must be addressed first to prevent harm and liability.

B. One staff member has not reported to work: While staffing shortages impact workload and coverage, they do not present an immediate physical danger. This issue can be addressed after eliminating urgent environmental risks.

C. A client's wife has asked to speak with the charge nurse: Family concerns are important and should be acknowledged, but they do not carry the urgency of an environmental safety threat. The nurse can follow up after resolving more pressing issues.

D. The census report has not been completed: Completing paperwork is essential for administrative tracking and planning, but it does not directly impact client safety. It should be prioritized after more urgent clinical and safety concerns are handled.

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Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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