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?
"A provider can write a prescription for restraints 'as needed"."
"I should tie the restraints using a square knot."
"I need to tie the restraint to the part of the bed frame that moves."
"I will remove a client's restraints every 4 hours."
The Correct Answer is B
Choice A Reason:
Restraints should never be prescribed on an "as needed" basis (PRN). Each application of restraints requires a specific and current provider order.
Choice B Reason:
Apply the appropriate restraint, using a clove hitch or a square knot. When applying restraints, using a square knot is essential to ensure that the restraints remain secure but can be easily removed in case of an emergency. A square knot provides a balance between security and quick release when needed.
Choice C Reason:
Restraints should be tied to a non-movable part of the bed frame, not to a part that moves, to prevent injury to the client.
Choice D Reason:
Restraints should be checked and removed more frequently, typically every 2 hours, to assess the client’s skin integrity and circulation, and to provide range-of-motion exercises.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Raising all four side rails on the bed of a confused client can be considered a form of restraint, which should be avoided unless necessary for the safety of the patient. It may infringe on the client's autonomy and dignity.
Choice B Reason:
Electing not to care for a client who had an abortion is discriminatory and violates the principle of nonmaleficence (doing no harm). Nurses have a professional obligation to provide care to all patients regardless of their personal beliefs or circumstances.
Choice C Reason:
Withholding nutrition from a client with a do-not-resuscitate (DNR) order without clear medical indications goes against the principle of beneficence and could be considered unethical. Nutritional support is a basic aspect of care that should not be withheld unless it is medically indicated or aligns with the patient's wishes.
Choice D Reason:
A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min represents ethical practice because administering prescribed opioids to a client with a terminal illness and a respiratory rate of 8/min is appropriate and aligns with the principle of beneficence. The nurse's action aims to alleviate the client's pain and suffering, which is essential in end-of-life care.
Correct Answer is A
Explanation
Choice A Reason:
A sufficient supply of personal protective equipment is appropriate. Bioterrorism events can involve the deliberate release of biological agents, such as bacteria, viruses, or toxins, with the intent to cause harm to individuals or populations. In such events, personal protective equipment (PPE) is critical for protecting healthcare workers and first responders from exposure to infectious agents and toxins. Adequate supplies of PPE, including masks, gloves, gowns, and eye protection, are essential to ensure the safety of healthcare workers and to prevent the spread of infection.
Choice B Reason:
A network for communication between staff members and families, is important for coordinating care and providing updates during a disaster, but it is not the highest priority when addressing immediate safety concerns related to a bioterrorism event.
Choice C Reason:
A mental health specialist on the response team, is important for providing support to individuals affected by the disaster, but it is not the highest priority during the initial response phase focused on safety and containment.
Choice D Reason:
A system for tracking client information, is important for maintaining continuity of care and tracking patient outcomes, but it is not the highest priority in the immediate response to a bioterrorism event when protecting healthcare workers and preventing further spread of infection is paramount.
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