A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Document the client’s condition every 15 min.

Request a PRN restraint prescription for clients who are aggressive.

Attach the restraint to the bed’s side rails.

Remove the client’s restraint every 4 hr.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Documenting the client’s condition every 15 minutes is a crucial part of using restraints. Regular documentation helps ensure the safety and well-being of the client, as it allows for continuous monitoring and timely intervention if necessary.

Choice B rationale:

Requesting a PRN (as needed) restraint prescription for clients who are aggressive is not a recommended practice. Restraints should only be used as a last resort and must be based on a thorough assessment of the client’s condition, not solely on their behavior.

Choice C rationale:

Attaching the restraint to the bed’s side rails is not recommended. This can increase the risk of injury to the client. Restraints should be attached to a part of the bed frame that moves with the client, such as the head or footboard.

Choice D rationale:

While it’s important to regularly check and adjust restraints for comfort and safety, there’s no specific guideline that restraints should be removed every 4 hours. The frequency of removal and repositioning will depend on the individual client’s condition and needs.

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Correct Answer is A

Explanation

Hematuria is the presence of red blood cells in the urine, which can make it appear pink or cola-colored. Hematuria is a common sign of glomerulonephritis, which is inflammation of the tiny filters in the kidneys (glomeruli) that remove waste and excess fluid from the blood. Hematuria occurs because the inflamed glomeruli allow some blood cells to leak into the urine.

Choice B is wrong because polyuria is the production of abnormally large amounts of urine. Polyuria is not a typical feature of acute glomerulonephritis, which may actually cause reduced urine output due to fluid retention and decreased kidney function.

Choice C is wrong because weight loss is not a common symptom of acute glomerulonephritis. On the contrary, weight gain may occur due to fluid retention and edema (swelling) in the face, hands, feet and abdomen.

Choice D is wrong because hypotension is low blood pressure. Hypotension is not usually associated with acute glomerulonephritis, which may cause high blood pressure (hypertension) due to fluid overload and impaired sodium excretion by the kidneys.

Normal ranges for blood pressure are less than 120/80 mmHg for adults. Normal ranges for urine output are about 800 to 2000 mL per day for adults.

Normal ranges for protein in the urine are less than 150 mg per day for adults. Normal ranges for red blood cells in the urine are less than 3 per high-power field for men and less than 5 per high-power field for women.

A. “The client was intubated without complications.”. B. “There was a total of 10 sponges used during the procedure.”. C. “The estimated blood loss was 250 milliliters.”. D. “The client is a member of the board of directors.”.

Correct Answer is C

Explanation

This statement should be included in the hand-off report because it provides essential information about the patient’s intraoperative status and potential postoperative complications, such as hypovolemia, anemia, or infection. The estimated blood loss (EBL) is an important indicator of the patient’s fluid balance and hemodynamic stability.
Choice A is wrong because “The client was intubated without complications.” is not relevant to the postoperative care of the patient. The intubation status is usually documented in the anesthesia record and does not need to be repeated in the hand-off report unless there were any issues or injuries related to the airway management.

Choice B is wrong because “There was a total of 10 sponges used during the procedure.” is not pertinent to the postoperative care of the patient.
The number of sponges used during the surgery is usually counted and verified by the scrub nurse and the circulating nurse in the operating room to prevent any retained foreign bodies. This information does not need to be communicated to the PACU nurse unless there was a discrepancy or a missing sponge.

Choice D is wrong because “The client is a member of the board of directors.” is not appropriate for the hand-off report.
This statement violates the patient’s privacy and confidentiality and does not contribute to the quality or safety of care. The patient’s role or position in the organization should not influence the hand-off communication or the postoperative care.
A hand-off report is a critical communication tool that facilitates the transfer of care from one provider to another. It should include relevant information about the patient’s medical history, surgical procedure, intraoperative events, postoperative plan, and any concerns or potential problems. A standardized hand-off tool, such as SBAR (Situation, Background, Assessment, Recommendation), can help improve the consistency, accuracy, and completeness of the hand-off report.
Some normal ranges that may be useful for postoperative care are:
• Blood pressure: 90/60 mmHg to 120/80 mmHg
• Pulse: 60 to 100 beats/min
• Respiratory rate: 12 to 20 breaths/min
• Oxygen saturation: 95% to 100%
• Temperature: 36°C to 37.5°C
• Hemoglobin: 12 to 18 g/dL
• Hematocrit: 36% to 54%

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A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is C

Explanation

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