A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Observe the client's range of movement.

Identify stressors that caused the client's aggression.

Hold a critical incident debriefing about the client.

Maintain sensory stimulation for the client.

Answer and Explanation

The Correct Answer is B

A. Observe the client's range of movement: While monitoring physical status is important, mechanical restraints restrict movement, so assessing the client’s psychological triggers and safety is higher priority to prevent further aggression.

B. Identify stressors that caused the client's aggression: Understanding and addressing the factors that led to aggressive behavior is essential while the client is in restraints. This assessment helps in developing strategies to reduce agitation and prevent future episodes.

C. Hold a critical incident debriefing about the client: Debriefing is conducted after the event to support staff and evaluate interventions. It is not performed while the client is actively restrained.

D. Maintain sensory stimulation for the client: Providing excessive sensory stimulation during restraint can increase agitation and risk of injury. The focus should be on calming the client and ensuring safety rather than maintaining stimulation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Tetracycline 200 mg PO: This prescription is incomplete because it does not specify the frequency or duration of administration, making it unclear how the medication should be given safely.

B. Cimetidine PO twice daily: The prescription lacks the dosage strength in milligrams, which is essential for accurate administration and safe dosing.

C. Digoxin 0.25 mg PO daily: This prescription includes the medication name, dosage, route, and frequency, providing all essential components needed for safe administration.

D. Epoetin alfa 150 units/kg three times weekly: While it includes dose and frequency, it does not specify the route (subcutaneous or IV), which is required to complete the prescription safely.

A. Explain to the client that transfusion reactions are not serious B. Insert a large-bore IV catheter. C. Witness the client signing a consent for transfusion D. Flush the transfusion tubing with dextrose 5% in water E. Have a second nurse confirm the information on the blood lab

Correct Answer is ["B","C","E"]

Explanation

Rationale for correct choices:

Insert a large-bore IV catheter: A large-bore IV (18–20 gauge) is necessary to allow rapid administration of blood products and reduce hemolysis of red blood cells during transfusion. This ensures safe and effective delivery of the blood components.
Witness the client signing a consent for transfusion: Informed consent is required before initiating a blood transfusion. The nurse ensures that the client understands the purpose, risks, and potential complications, and witnesses the signing to meet legal and ethical standards.
Have a second nurse confirm the information on the blood lab: Verifying the blood type, crossmatch, and client identifiers with a second nurse reduces the risk of transfusion errors and ensures patient safety before starting the transfusion.

Rationale for incorrect choices:

Explain to the client that transfusion reactions are not serious: Transfusion reactions can be serious, including hemolytic reactions, febrile reactions, or allergic responses. The nurse should educate the client on the potential risks and signs of a reaction rather than minimizing them.
Flush the transfusion tubing with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride (normal saline). Flushing with dextrose or other solutions can cause hemolysis and compromise the safety of the transfusion.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?

Correct Answer is C

Explanation

The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion, which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about managing the disease. The nurse should emphasize the importance of which of the following factors to prevent a sickle cell crisis?

A nurse in a provider's office is caring for a client who has asthma and reports that the manifestations get worse while exercising. Which of the following statements should the nurse make?

A nurse in the infectious disease division of the local health department is caring for a client. Which of the following infections should the nurse identify should be reported to the health department?

A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team?

A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?