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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct answer: B
A.Family presence can provide comfort and support to the toddler, making mealtimes a more positive experience. It can also encourage the child to eat more by setting a good example. However, without first understanding the child's dietary habits and possible issues, this intervention might not address the root cause of the poor intake.
B.The nurse’sfirst actionin caring for a toddler with poor dietary intake should be toobtain the child’s dietary history. Understanding the child’s current eating habits, preferences, and any potential barriers to adequate nutrition is essential for planning appropriate interventions. Once the dietary history is obtained, the nurse can tailor further actions based on the specific needs of the child.
C.Offering nutritious snacks can help increase the child's overall calorie and nutrient intake, which is particularly important if the child has a low appetite during regular meals. Nevertheless, this step should follow the assessment of the child's dietary history to ensure that the snacks offered are appropriate and to avoid potential allergies or intolerances.
D.Positive reinforcement can encourage healthy eating behaviors and make mealtime a more enjoyable experience for the child. Praising the child can motivate them to eat more. However, this should be done after understanding the child's eating patterns and preferences to ensure that the praise is given in a context that promotes effective and lasting change.
Correct Answer is A
Explanation
A.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
B.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
C.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
D.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
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