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?

Hold a critical incident debriefing about the client.

Observe the client’s range of movement.

Maintain sensory stimulation for the client.

Identify stressors that caused the client’s aggression.

Answer and Explanation

The Correct Answer is B

Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.

Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.

Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.

Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.

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Correct Answer is C

Explanation

Choice A reason: Wrapping sterile gauze for bleeding is inappropriate; gentle pressure and provider notification are needed. Petroleum jelly prevents adhesion. Using gauze risks infection or trauma, critical to avoid in ensuring safe circumcision healing, supporting parental care, and preventing complications in newborns post-procedure.

Choice B reason: Removing yellow exudate, a normal healing sign, risks disrupting the circumcision site, causing pain or infection. Petroleum jelly is correct. Assuming removal is needed risks delayed healing, critical to prevent in ensuring proper wound care and parental education for newborns post-circumcision.

Choice C reason: Applying petroleum jelly to the glans with diaper changes prevents diaper adhesion, promotes healing, and reduces discomfort post-circumcision. This instruction is critical for parental care, ensuring infection prevention, supporting newborn comfort, and facilitating proper healing in the sensitive post-procedure period.

Choice D reason: Using soap on the circumcision site risks irritation and delayed healing; gentle water cleansing is preferred. Petroleum jelly is appropriate. Assuming soap is safe risks discomfort or infection, critical to avoid in ensuring proper care and healing for newborns following circumcision procedures.

A. Elevate the head of the client’s bed to 45°. B. Assess the client’s peripheral pulses every 15 minutes. C. Change the client’s dressing 4 hours following the procedure. D. Instruct the client to flex the right knee every 30 minutes.

Correct Answer is B

Explanation

Choice A reason: Elevating the bed to 45° increases bleeding risk at the femoral site post-catheterization; flat positioning is preferred. Assessing pulses is priority. Elevating risks hematoma, critical to avoid in ensuring vascular safety, monitoring for complications, and supporting recovery in immediate postoperative cardiac catheterization care.

Choice B reason: Assessing peripheral pulses every 15 minutes post-femoral catheterization monitors for arterial occlusion or bleeding, critical for detecting complications like hematoma or thrombosis. This ensures timely intervention, essential for vascular integrity, preventing limb ischemia, and supporting safe recovery in the immediate postoperative period.

Choice C reason: Changing the dressing 4 hours post-catheterization is premature unless soiled; initial monitoring of pulses is priority. Assuming dressing change is urgent risks disrupting the site, increasing bleeding, critical to avoid in ensuring site stability and vascular safety in immediate post-catheterization care.

Choice D reason: Flexing the right knee is contraindicated post-femoral catheterization, risking site disruption or bleeding; leg immobility is required. Assessing pulses is key. Instructing flexion risks hematoma, critical to prevent in ensuring vascular safety, monitoring complications, and supporting recovery in postoperative cardiac catheterization clients.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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