A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

Obtain a prescription for restraints from the provider.

Document the indications for using wrist restraints.

Explain the procedure to the client and their family.

Attempt less restrictive alternatives.

Answer and Explanation

The Correct Answer is D

A.   While a prescription may be necessary, attempting less restrictive alternatives should be the first action.
B.   Documentation is important but should not precede attempting less restrictive alternatives.
C.   Education about the use of restraints is important but should follow attempts at less restrictive alternatives.
D.   The nurse should exhaust all possible alternatives to restraints before considering their use, in line with the principle of least restrictive intervention.

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Correct Answer is B

Explanation

A. While durable power of attorney may come into effect if the client becomes incapacitated, it specifically pertains to healthcare decision-making rather than self- care activities.
B. Durable power of attorney for healthcare decisions is enforceable when the client is unable to make or communicate their own healthcare decisions.
C. Terminal illness may be a factor in the decision-making process, but durable power of attorney is not contingent upon terminal illness.
D. Refusal of treatment is a separate issue from durable power of attorney and does not directly relate to the enforceability of a healthcare proxy.

A. "Use povidone-iodine to clean around the stoma." B. "Cut the opening of the pouch / of an inch larger than the stoma." C. "Empty the ostomy pouch when it becomes one-third full of contents." D. "Place a piece of gauze over the stoma while changing the pouch." E. "Expect the stoma to turn a purple-blue color as it heals."

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

Explanation

A. Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B. Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C. Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D. The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E. A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.

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A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?

Correct Answer is B

Explanation

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

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

Explanation

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