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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Warfarin is a vitamin K antagonist that inhibits the synthesis of factors II, VII, IX, and X in the liver. These factors are part of the extrinsic and common pathways of coagulation, which are measured by the prothrombin time (PT) and the international normalized ratio (INR). The INR is a standardized way of reporting the PT that accounts for the variability of different reagents and instruments. The INR is used to monitor the therapeutic effect of warfarin and to adjust the dose accordingly. The target INR range depends on the indication for warfarin, but it is usually between 2 and 3 for most conditions.
Choice B is wrong because fibrinogen level is not affected by warfarin.
Fibrinogen is a precursor of fibrin, which forms the final step of the coagulation cascade.
Fibrinogen level can be decreased in conditions such as disseminated intravascular coagulation (DIC), liver disease, or severe bleeding.
Choice C is wrong because aPTT is not affected by warfarin.
aPTT measures the intrinsic and common pathways of coagulation, which are mainly dependent on factors VIII, IX, XI, and XII.
These factors are not inhibited by warfarin.
aPTT is used to monitor the effect of heparin, a direct antithrombin agent that inhibits thrombin and factor Xa.
Choice D is wrong because platelet count is not affected by warfarin.
Platelets are cell fragments that adhere to damaged blood vessels and form aggregates to initiate hemostasis.
Platelet count can be decreased in conditions such as immune thrombocytopenia (ITP), heparin-induced thrombocytopenia (HIT), or bone marrow suppression.
Correct Answer is C
Explanation
Valsartan is a medication that lowers blood pressure by blocking the action of angiotensin II, a hormone that causes blood vessels to constrict. By dilating the blood vessels, valsartan reduces the pressure in the arteries and improves blood flow to the organs. However, if the dose of valsartan is too high, it can cause excessive lowering of blood pressure, which can lead to symptoms such as dizziness, fainting, blurred vision, or nausea. This is especially likely when the client changes position from lying or sitting to standing, which is called orthostatic hypotension. Therefore, the nurse should monitor the client’s blood pressure and pulse in different positions and report any significant changes to the provider. The nurse should also instruct the client to rise slowly from a lying or sitting position and to avoid driving or operating machinery until the effects of the medication wear off.
Choice A is wrong because monitoring the client’s urine output is not a priority action for a client who received an overdose of valsartan.
Valsartan does not have a direct effect on urine output, although it may affect kidney function in some cases. The nurse should monitor the client’s serum creatinine and blood urea nitrogen levels to assess kidney function, but this is not as urgent as evaluating the client for orthostatic hypotension.
Choice B is wrong because checking the client for nasal congestion is not a priority action for a client who received an overdose of valsartan.
Nasal congestion is not a common or serious side effect of valsartan. It is more likely to occur with other types of blood pressure medications, such as angiotensin-converting enzyme (ACE) inhibitors or beta blockers.
Choice D is wrong because obtaining the client’s laboratory results is not a priority action for a client who received an overdose of valsartan.
Laboratory results may provide useful information about the client’s electrolyte levels, kidney function, liver function, or blood counts, but they are not as important as assessing the client’s vital signs and symptoms of hypotension. The nurse should obtain the laboratory results after stabilizing the client’s blood pressure and ensuring adequate perfusion to the organs.
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