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 B
Explanation
A) Allowing the infant to have soft foods is not recommended immediately following surgery to protect the surgical site.
B) Maintaining elbow restraints prevents the infant from touching or injuring the repair site, which is crucial for proper healing.
C) Feeding the infant with a spoon could disrupt the surgical site and is not advised until cleared by a healthcare provider.
D) While oral hygiene is important, brushing the infant's teeth could harm the repair site; however, specific post-operative care instructions regarding oral hygiene should be provided by the healthcare provider, which may or may not include a temporary cessation of brushing.
Correct Answer is B
Explanation
A. The client's foot feels cooler than in the previous assessment: While decreased temperature can indicate decreased perfusion, the absence of a palpable pedal pulse is a more concerning finding.
B. The client's pedal pulse in the right foot is not palpable: This finding suggests compromised blood flow distal to the site of the bypass graft, which could indicate graft occlusion or impaired circulation.
C. The client's capillary refill time is 5 seconds in the toes: While prolonged capillary refill time can indicate impaired circulation, the absence of a palpable pedal pulse is a more concerning finding.
D. The client reports a pain level of 8 on a scale from 3 to 10: Pain is subjective and can be managed with analgesics, but the absence of a palpable pedal pulse indicates a more serious issue related to perfusion.
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