A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I need to tie the restraint to the part of the bed frame that moves."
"I should tie the restraints using a square knot."
"I will remove a client's restraints every 4 hours."
"A provider can write a prescription for restraints as needed."
The Correct Answer is A
Rationale:
A. Restraints should always be tied to a part of the bed frame that moves with the client (not to side rails), using a quick-release knot to ensure client safety.
B. A square knot is unsafe because it is difficult to untie quickly in an emergency. Quick-release knots should be used instead.
C. Restraints must be removed at least every 2 hours (not every 4) to assess skin, circulation, and provide ROM exercises.
D. A provider’s prescription for restraints must be time-limited and specific; prescriptions "as needed" (PRN) are not allowed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Documenting assessment data is important but should follow planning and prioritization of care.
B. Reviewing new laboratory values is necessary for informed care but is part of the assessment and planning process, not the first step.
C. Completing required tasks without prioritization can lead to inefficient use of time and missed critical care.
D. Determining client care goals allows the nurse to prioritize tasks and plan the shift effectively, making it the first and most important step in time management.
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Identifying all witnesses ensures that accurate accounts of the event are available for investigation.
B. It is the responsibility of the nurse who witnessed the incident, not the coworker, to report the occurrence.
C. Submitting an incident report to the risk manager is appropriate to initiate a formal review and ensure compliance with legal and facility requirements.
D. Anonymous reporting is discouraged because it may limit the ability to investigate and follow up appropriately.
E. Documenting a factual, objective account provides a clear record of the incident without personal bias or judgment.
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