A nurse assesses a patient with restraints. The nurse should:
Loosen the restraints and assess the patient’s skin.
Document the findings in the patient’s chart.
Continue to monitor the patient without making any changes.
Apply ice packs to reduce swelling.
The Correct Answer is B
Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Quasi-experimental research involves the manipulation of an independent variable to determine its effect on a dependent variable, similar to experimental research. However, quasi-experimental designs lack random assignment to groups, which can limit the ability to infer causality. Despite this limitation, quasi-experimental designs are valuable for studying causal relationships in real-world settings where random assignment is not feasible.
Choice B rationale
Correlational research examines the relationship between two or more variables without manipulating any variables. It does not involve the manipulation of an independent variable or the use of control groups, making it distinct from quasi-experimental research.
Choice C rationale
Qualitative research focuses on exploring and understanding the meaning and experiences of individuals through methods such as interviews, observations, and content analysis. It does not involve the manipulation of variables or the use of experimental designs, making it distinct from quasi-experimental research.
Choice D rationale
Quantitative research involves the collection and analysis of numerical data to identify patterns, relationships, and trends. While quasi-experimental research is a type of quantitative research, not all quantitative research involves quasi-experimental designs. Quantitative research can also include experimental, correlational, and descriptive designs.
Correct Answer is C
Explanation
Choice A rationale
A newly admitted client with a seizure disorder requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.
Choice B rationale
A post-op laparotomy client who is waiting for discharge instructions requires specific education and assessment, which is beyond the scope of practice for a nursing assistant.
Choice C rationale
A client who needs assistance with feeding is the correct answer. Assisting with feeding is within the scope of practice for a nursing assistant.
Choice D rationale
A dehydrated client with an electrolyte imbalance requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.
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