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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Among the given options, 240 mL (8 oz) of hot cocoa typically contains the least amount of caffeine. While the exact caffeine content can vary depending on the brand and preparation method, hot cocoa is generally considered to have a lower caffeine content compared to brewed green tea, instant coffee, or cola soft drinks.

However, it's worth noting that hot cocoa may still contain a small amount of caffeine, although significantly less than the other options mentioned.

A. Decrease daily fluid intake. B. Withhold the medication if pulse rate is less than 60/min C. Rise slowly from a sitting position to a standing position D. Increase dietary potassium

Correct Answer is C

Explanation

Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.

Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.

While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.

While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.

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A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine? Brewed green tea Hot cocoa Instant coffee Cola soft drink

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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