A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?

Offer the client fluids and toileting every 15 min.

Obtain a prescription before removing the restraints.

Ensure the restraints are removed from the client within 6 hr.

Place the client in prone position on a soft mattress.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.

B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.

C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.

D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.

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Correct Answer is B

Explanation

Rationale:

A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.

B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.

C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.

D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.

A. Severe immunodeficiency B. Asymptomatic HIV C. Mild febrile illness D. Egg allergy

Correct Answer is A

Explanation

Rationale:

A. Severe immunodeficiency: The MMR vaccine is a live attenuated vaccine and is contraindicated in clients with severe immunodeficiency, such as those undergoing chemotherapy or with advanced HIV/AIDS. These individuals cannot mount an appropriate immune response, placing them at risk for vaccine-related complications.

B. Asymptomatic HIV: Clients with asymptomatic HIV and adequate CD4 counts may safely receive the MMR vaccine. It is not contraindicated unless the client is significantly immunocompromised.

C. Mild febrile illness: Mild illnesses, such as low-grade fever or upper respiratory infections, do not contraindicate vaccine administration. The MMR vaccine can still be safely given, as minor illness does not significantly alter vaccine response or increase risks.

D. Egg allergy: Although the MMR vaccine is cultured in chick embryo fibroblasts, it does not contain significant egg protein, and studies have shown it can be safely administered to individuals with egg allergies. An egg allergy is not a valid reason to withhold the vaccine.

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A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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