A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?
Tie the restraints to the side rails of the child's bed.
Request that the provider renew the prescription for restraints every 48 hr.
Secure the restraints with a quick-release knot.
Assess the child every 4 hr while in restraints.
The Correct Answer is C
A. Tying restraints to the side rails poses a risk of injury to the child and is not a recommended practice.
B. Renewing the prescription for restraints every 48 hours is important, but it does not directly address the proper application of restraints.
C. Securing restraints with a quick-release knot allows for quick removal in case of emergency and is the correct method for applying restraints.
D. Assessing the child every 4 hours while in restraints is important, but it does not address the proper application of restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Inspecting the epiglottis is contraindicated in suspected cases of epiglottitis as it may trigger laryngospasm and compromise the airway.
B. Obtaining a throat culture may be indicated to confirm the presence of Haemophilus influenzae type B but is not an immediate priority in the management of epiglottitis.
C. Monitoring oxygen saturation is crucial as respiratory distress and hypoxia are common complications of epiglottitis.
D. Beginning droplet precautions is important to prevent the spread of the infectious agent to others.
E. Initiating IV access is necessary for administering fluids and medications, as well as for potential airway management in severe cases of epiglottitis.
Correct Answer is B
Explanation
A. Maintaining extended eye contact may be uncomfortable or overwhelming for a child with autism spectrum disorder (ASD) and may not be an appropriate intervention.
B. Establishing a reward system can help reinforce positive behaviors and encourage desired outcomes in children with ASD.
C. Engaging in cooperative play may be challenging for a child with ASD due to difficulties with social interaction and communication.
D. Holding the child during assessments may cause distress or discomfort for a child with ASD and may not be necessary for the assessment process.
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