A nurse is observing a client who is in four-point restraints for violent and self-destructive behavior. Which of the following actions should the nurse take when using four-point restraints?
Assess the client every hr for circulation, possible injury, and readiness for discontinuation.
Check the client's peripheral pulses and skin integrity every 15 min.
Assist the client with passive range of motion exercises every 3 hr.
Attach the extremity restraint straps to the bed rails using a quick-release buckle.
The Correct Answer is B
A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation: While regular assessment is necessary, it should be done more frequently than every hour. A check every 15-30 minutes is recommended for safety.
B. Check the client's peripheral pulses and skin integrity every 15 min: Frequent assessments of circulation, skin integrity, and injury help prevent complications like tissue damage or nerve impairment.
C. Assist the client with passive range of motion exercises every 3 hr: Passive range of motion exercises should be done more frequently than every 3 hours to prevent stiffness and joint contractures.
D. Attach the extremity restraint straps to the bed rails using a quick-release buckle: Restraints should never be attached to bed rails, as this increases injury risk. Straps should be secured to a stationary part of the bed frame.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.
B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.
C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.
D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.
Correct Answer is D
Explanation
A. The Emergency Medical Treatment and Active Labor Act requires that emergency care be provided regardless of the client’s behavior, as long as the client is seeking treatment for an emergency medical condition.
B. EMTALA requires that a client receive a medical screening and stabilization before being transferred, regardless of whether the condition is terminal. A terminal diagnosis does not justify transferring a client without stabilization first.
C. EMTALA prohibits discrimination based on a client’s ability to pay. A client cannot be transferred or discharged from an emergency department based on their inability to pay for services.
D. EMTALA requires that a client must be stabilized before being transferred to another facility. This ensures that the client is not placed at risk by the transfer, and the new facility is prepared to manage their care appropriately.
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