A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.
Complete the following sentence by selecting the most appropriate actions based on the client’s current status.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
The nurse should first: Response 1: Notify the primary health care provider immediately.
This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.
Then, the nurse should: Response 2: Start an IV line for potential medication administration.
Starting an IV line ensures that the client can receive any necessary medications quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.
Choice B rationale
Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.
Choice C rationale
Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.
Choice D rationale
Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.
Choice B rationale
Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.
Choice C rationale
A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.
Choice D rationale
Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.
Choice E rationale
Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.
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