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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Reviewing facility policies is important but should follow understanding the underlying cause of the issue.
B. Discussing time management strategies may be helpful but is premature without knowing why breaks are being missed.
C. Providing coverage for breaks is a possible solution, but it should be based on identified barriers.
D. Determining the reasons the nurses are not taking breaks is the first step, as it allows the charge nurse to address the root cause and implement an appropriate and effective solution.
Correct Answer is ["A","C"]
Explanation
Rationale:
A. The obturator is needed in case the tracheostomy tube becomes dislodged, allowing safe reinsertion.
B. Cotton balls should not be used near the tracheostomy because fibers can be inhaled and cause airway obstruction.
C. An oxygen tank may be required to ensure adequate oxygenation at home, especially if the client has respiratory compromise.
D. Pipe cleaners are unsafe for cleaning tracheostomy equipment because they can leave particles or cause trauma. Only sterile, manufacturer-approved cleaning devices should be used.
E. Petroleum jelly is not recommended because it can occlude the airway and increase infection risk; water-based lubricants are preferred if lubrication is necessary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.