A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?
Document in the client's medical record every 15 min.
Offer toileting to the client every 4 hr.
Remove the restraint when the client falls asleep.
Request that the provider write an as-needed prescription for restraints.
The Correct Answer is A
A. Documenting in the client's medical record every 15 minutes is essential to monitor the client's status, including physical and psychological well-being, while in restraints. Accurate documentation ensures that any changes or responses to the intervention are recorded and communicated to other healthcare providers.
B. Offering toileting to the client every 4 hours may be necessary depending on the client's
individual needs, but it does not address the immediate need for monitoring the client's safety and well-being while restrained.
C. Removing the restraint when the client falls asleep is not appropriate without a healthcare provider's order. Restraints should only be removed based on a specific criteria set forth by
institutional policies or as directed by the healthcare provider.
D. Requesting an as-needed prescription for restraints is not appropriate. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a healthcare provider's assessment and orders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Viral pneumonia can be highly contagious, so placing the client in a private room can help prevent the spread of the infection to other patients.
B. Incorrect. Azithromycin is an antibiotic typically used for bacterial infections and would not be indicated for viral pneumonia.
C. Incorrect. Pneumococcal immunization is effective for preventing bacterial pneumonia caused by Streptococcus pneumoniae but is not indicated for viral pneumonia.
D. Incorrect. Limiting fluid intake to 1 L per day is not appropriate for a client with viral pneumonia, as adequate hydration is important for supporting the body's immune response and preventing dehydration.
Correct Answer is C
Explanation
A. Asking the client to help with the dressing change may not be appropriate, especially if the client is frail or recovering from surgery. Older adults may have limited mobility or strength, and they may require assistance rather than being asked to participate actively.
B. Waiting for the client to approach the nurse for assistance may not be conducive to providing optimal care. Nurses should proactively assess the client's needs and offer assistance as appropriate, especially in the postoperative period when mobility may be limited.
C. Using paper tape for securing the new dressing is a good choice because older adults may have delicate skin that is prone to tearing or irritation. Paper tape is gentle on the skin and less likely to cause damage or discomfort compared to other types of adhesive dressings.
D. Applying the dressing loosely over the incision may compromise its effectiveness in providing wound protection and promoting healing. Dressings should be applied securely but not too tightly to avoid restricting circulation or causing discomfort.
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