A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Monitor the client's range of motion every 60 min.

Offer the client a nutritious snack every 4 hr.

Plan to remove the restraints as soon as the client is calm

Ensure that the provider has signed a prescription for restraints within 48 hr.

Answer and Explanation

The Correct Answer is C

The correct answer is C. Plan to remove the restraints as soon as the client is calm. Physical restraints should be used as a last resort and for the shortest duration possible to ensure

client safety. The nurse should assess the client frequently and remove the restraints when they are no longer needed.

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Correct Answer is D

Explanation

The correct answer is D. The telephone numbers of the clients are unique identifiers that can be used to verify their identities before administering medications. The room numbers, diagnoses, and names of relatives are not reliable identifiers because they can change or be shared by other clients.

A. "Ensure the bath water is at least 96 degrees Fahrenheit." B. "Perform sponge baths until the baby's umbilical cord falls off." C. "Apply talcum powder daily after bathing in order to prevent diaper rash." D. "Use an alkaline soap to bathe the baby."

Correct Answer is B

Explanation

The correct answer is B. Performing sponge baths until the baby's umbilical cord falls off is a recommended practice to prevent infection and promote healing of the cord stump. The bath water should be warm but not hot, around 85 to 90 degrees Fahrenheit. Talcum powder can irritate the baby's skin and lungs and should be avoided. Alkaline soap can dry out the baby's skin and should be replaced with a mild, pH-balanced cleanser.

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A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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