A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
Apply the restraint under the client's clothes.
Tie the restraint to the railing of the client's bed.
Place the client in a sitting position.
Ensure the restraint is placed across the client's chest.
The Correct Answer is C
a. Applying the restraint under the client's clothes: Restraints should be applied over the client's clothes to avoid direct skin contact and reduce the risk of skin irritation or injury.
b. Tying the restraint to the railing of the client's bed: Restraints should not be tied to bed rails or any other fixed objects. This can increase the risk of injury to the client and should be avoided.
c. Placing the client in a sitting position is appropriate when applying a belt restraint, as it helps prevent respiratory compromise and allows the client to maintain a safer and more comfortable posture.
d. A belt restraint should be placed around the client's waist, not across the chest, to avoid restricting breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.
Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.
Prothrombin time (PT) is a test used to evaluate the clotting ability of the blood and is not directly related to thyroid function or levothyroxine therapy.
Arterial blood gases (ABGs) are used to assess oxygen and carbon dioxide levels in the blood and evaluate acid-base balance. ABGs are not specifically related to thyroid function or levothyroxine therapy.
Correct Answer is A
Explanation
Understanding the client's current voiding pattern is essential in developing an effective bladder training program. By determining the client's pattern for voiding, the nurse can identify any irregularities, frequency, and specific times when the client is more likely to void. This information will serve as a baseline for developing an individualized bladder training program. Offering toileting opportunities every 1 to 2 hours is an appropriate intervention to ensure regular and scheduled voiding. However, before implementing this intervention, it is necessary to determine the client's current voiding pattern to identify any existing irregularities or potential areas of improvement.
Assisting the client with relaxation techniques can help promote effective voiding and reduce anxiety or stress related to the act of voiding. However, this intervention can be more effective once the nurse has assessed the client's voiding pattern and identified specific areas where relaxation techniques can be beneficial.
Discouraging intake of carbonated beverages is a valid intervention as carbonated beverages can irritate the bladder and contribute to increased frequency and urgency of urination. However, this intervention can be implemented as part of a comprehensive bladder training program after the nurse has assessed the client's current voiding pattern and developed an individualized plan.
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