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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"Clients who participate in research studies forfeit their HIPAA right to privacy. "This statement is incorrect. While research studies may involve the use of personal health information, participants still retain their HIPAA rights to privacy. Research institutions are required to follow strict guidelines for protecting participants' privacy and confidentiality.
Choice B Reason:
"HIPAA prohibits the uploading of photographs of client's providers to social media sites. "This statement is true. HIPAA prohibits the unauthorized disclosure of protected health information (PHI), which includes photographs, on social media or any other public platform without the patient's explicit consent.
Choice C Reason:
"HIPAA allows facility-specific coding of client health care information to ensure privacy." This statement is ambiguous and could be interpreted in different ways. HIPAA requires covered entities to implement safeguards to protect the privacy of health information, which may include coding or encryption of data. However, facility-specific coding alone may not be sufficient to ensure privacy compliance without proper implementation of HIPAA privacy and security standards.
Choice D Reason:
"HIPAA allows clients to request a review of their own medical records. “This statement is correct. HIPAA grants individuals the right to access and review their own medical records held by covered entities, such as healthcare providers and health plans. This access allows patients to verify the accuracy of their medical information and understand how their health information is being used and disclosed.
Correct Answer is C
Explanation
Choice A Reason:
The time the client received his last dose of pain medication is incorrect. While this information is relevant for ongoing pain management, it may not be as critical for the receiving facility unless there are specific pain management protocols in place that need to be followed.
Choice B Reason:
The client's preferred time for bathing is incorrect. While knowing the client's preferences is important for providing individualized care, the preferred time for bathing may not be immediately pertinent to the client's care upon transfer to the rehabilitation facility.
Choice C Reason:
The steps to follow when providing wound care is correct. This information is essential for the receiving facility to ensure proper wound care continues without interruption. It helps ensure consistency in care and minimizes the risk of complications related to wound healing.
Choice D Reason:
The belief that the client has a difficult relationship with his son is incorrect. While psychosocial information about the client is important for holistic care, it may not be the most crucial information to include in the change-of-shift report for transfer to a rehabilitation facility unless it directly impacts the client's medical care or rehabilitation plan.
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