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 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.
Correct Answer is D
Explanation
Choice A Reason:
Completing an incident report is inappropriate. While completing an incident report is important for documenting any errors or deviations from the standard of care, it should not be the first action taken. Assessing the client's condition takes precedence to ensure their immediate safety and well-being.
Choice B Reason:
Notifying the provider is inappropriate. Notifying the provider may be necessary, but it should not be the first action taken. Initially, the nurse should assess the client's condition to determine if any adverse effects have occurred as a result of the additional medication dose.
Choice C Reason:
Informing the nursing supervisor is inappropriate. Informing the nursing supervisor may be appropriate, especially if further actions or investigations are needed. However, the immediate priority is to assess the client's condition to ensure their safety.
Choice D Reason:
Observing the client's condition is appropriate. The nurse should first assess the client's condition to determine if any adverse effects have occurred due to the additional medication dose. This assessment helps identify any immediate concerns that require intervention. Based on the client's condition, further actions such as notifying the provider or completing an incident report may be warranted. However, observing the client's condition is the initial and most immediate action to take.
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