A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

The provider should renew the prescription for restraints every 48 hr.

The nurse should pad the bony prominences.

The nurse should tie the restraints using a square knot.

The nurse should remove the restraints every 2 hr.

The provider's prescription should include the type of restraint to use.

Answer and Explanation

Correct Answer : B,D,E

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours.
B. Padding bony prominences helps prevent skin breakdown and pressure injuries.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in an emergency.
D. Removing the restraints every 2 hours allows for circulatory assessment, skin care, and range of motion exercises.
E. The provider's prescription should specify the type of restraint to ensure proper and appropriate use.

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Correct Answer is A

Explanation

A. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.

B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.

C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.

D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial

damage.

A. An air leak noted at the insertion site. B. The tubing may be kinked. C. Water needs to be added to the suction-control chamber. D. The suction is set too low.

Correct Answer is B

Explanation

A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.

B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.

C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.

D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.

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A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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