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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Controlled substances are kept in the bottom drawer of the medication cart.": Controlled substances are stored in locked, secure medication dispensing systems or locked drawers—not casually in the bottom drawer. Security measures are in place to prevent diversion and ensure accurate tracking.
B. "I should verify the number of controlled substances at the end of the shift. The provider is responsible for inventory of controlled substances.": While end-of-shift counts are standard practice, the nurse not the provider is responsible for verifying inventory at shift change. Accountability for handling and documenting controlled substances lies with nursing staff.
C. "If a controlled substance requires a waste, a second nurse must witness the waste.":
This is a correct and essential safety protocol. When wasting part of a controlled substance dose, a second licensed nurse must witness and document the waste to prevent diversion and ensure accurate medication tracking.
D. "Computer controlled substance inventory is reported to the Drug Enforcement Administration every 10 years.": Facilities are required to maintain records and conduct regular audits, and the DEA mandates inventory at least every 2 years not every 10. Reporting frequency and requirements are more stringent.
Correct Answer is B
Explanation
Rationale:
A. "This surgery can cause an increase in the amount of semen.":A transurethral resection of the prostate (TURP) often results in retrograde ejaculation, meaning semen may flow backward into the bladder. The volume of visible semen typically decreases, not increases, due to this common complication.
B. "I will talk to my partner about other ways of expressing intimacy.":This statement reflects healthy psychological adjustment and understanding of potential changes in sexual function following TURP. It shows emotional readiness to adapt to changes and maintain intimacy in ways beyond penetrative sex, which supports recovery and relationship stability.
C. “I will not be able to have sexual intercourse after this surgery.":TURP does not prevent sexual intercourse. While temporary issues like erectile dysfunction or retrograde ejaculation may occur, most clients can resume sexual activity after recovery. This belief represents a misunderstanding of surgical outcomes.
D. “This surgery will prevent me from being able to have an erection.": Although some men may experience temporary erectile dysfunction postoperatively, TURP typically does not cause permanent loss of erectile function. Misconceptions about impotence should be addressed through accurate education.
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