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:
Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.
Choice B Reason:
A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client. Negative-pressure rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.
Choice C Reason:
Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.
Choice D Reason:
An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.
Correct Answer is B
Explanation
Choice A Reason:
Escorting the nurses to the nurses' lounge to continue the discussion is incorrect. While removing the nurses from a public area to discuss the matter further might seem like a good idea, it does not address the underlying issue of unprofessional behavior and inappropriate discussion about patient care. The charge nurse should intervene to address the situation more formally.
Choice B Reason:
Contacting the house supervisor to mediate the conflict is correct. Contacting the house supervisor ensures that the issue is escalated appropriately and that a neutral party with authority can intervene to mediate the conflict. The house supervisor can help address the nurses' concerns while emphasizing the importance of professionalism and patient-centered care.
Choice C Reason:
Recommending that both nurses be terminated is incorrect. Termination should only be considered after a thorough investigation and due process. Jumping to termination as the first course of action is inappropriate and may not be warranted in this situation, especially without understanding the full context and reasons behind the nurses' behavior.
Choice D Reason:
Making arrangements to take over the client's care is incorrect. While ensuring continuity of care for the client is important, taking over the client's care without addressing the underlying issue of unprofessional behavior and inappropriate discussion about patient care does not address the root cause of the problem. It's important to address the behavior of the nurses through appropriate channels and ensure that they understand the importance of professionalism and patient confidentiality.
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