A nurse is considering the use of restraints. The nurse should:
Ensure that the patient has been adequately monitored.
Proceed with the application of restraints.
Explore alternative interventions to address the patient’s behavior.
Obtain verbal consent from the patient’s family.
The Correct Answer is C
Choice A rationale
Ensuring that the patient has been adequately monitored is important, but it is not the first step when considering the use of restraints. The nurse should first explore alternative interventions.
Choice B rationale
Proceeding with the application of restraints without considering alternatives can lead to unnecessary use of restraints, which can cause physical and psychological harm to the patient.
Choice C rationale
Exploring alternative interventions to address the patient’s behavior is the first step. Restraints should only be used as a last resort when other interventions have failed.
Choice D rationale
Obtaining verbal consent from the patient’s family is important, but it is not the first step. The nurse should first explore alternative interventions.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Following the order as prescribed without clarification can lead to errors if the order is unclear or incomplete.
Choice B rationale
Administering the medication at a later time without clarification can also lead to errors and may delay necessary treatment.
Choice C rationale
Disregarding the order and seeking approval from another physician is not appropriate. The nurse should seek clarification from the ordering physician.
Choice D rationale
Asking the physician to clarify the dosage and route ensures that the order is accurate and complete, reducing the risk of medication errors.
Correct Answer is B
Explanation
Choice A rationale
Ensuring the client can independently manage their care is important, but it does not directly address potential barriers that could affect adherence to the discharge plan. Identifying barriers is crucial to ensure the client can follow through with the plan safely and effectively.
Choice B rationale
Identifying potential barriers to adherence is essential for client safety during the discharge process. This includes assessing the client’s understanding of their care plan, their ability to access medications, and any social or financial obstacles that may hinder their adherence. By addressing these barriers, the nurse can help ensure the client follows the discharge plan and reduces the risk of complications or readmissions.
Choice C rationale
Avoiding discussion of dietary restrictions is incorrect because dietary restrictions are often a critical component of a client’s care plan. Discussing and ensuring the client understands these restrictions is vital for their safety and health management post-discharge.
Choice D rationale
Providing information quickly to expedite discharge is not a safe practice. It is important to ensure the client fully understands their discharge instructions, which requires taking the time to explain and confirm comprehension. Rushing through this process can lead to misunderstandings and potential harm.
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