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 D
Explanation
This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.
Choice A is wrong because rinsing the mouth with an alcohol-based mouthwash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.
Choice B is wrong because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia.
Esophageal speech involves swallowing air into the esophagus and releasing it to create sound.
It has nothing to do with saliva flow or dry mouth.
Choice C is wrong because saltine crackers are dry and hard to swallow without adequate saliva.
They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.
Normal ranges for saliva flow vary depending on the method of measurement, but generally, a stimulated saliva flow rate of less than 0.7 mL/min or an unstimulated saliva flow rate of less than 0.1 mL/min is considered indicative of xerostomia.
Correct Answer is B
Explanation
This is because the retention port is a sterile site that can be accessed by a syringe to aspirate urine without contaminating the specimen or the closed drainage system. The retention port should be cleaned with an alcohol swab before inserting the syringe. The specimen should be transferred to a sterile container and labeled appropriately.
Choice A is wrong because unclamping the collection port below the bag would allow urine to flow out of the bag, which is not sterile and may contain bacteria or sediment.
Choice C is wrong because disconnecting the catheter from the collection tubing would break the closed drainage system and increase the risk of infection.
Choice D is wrong because using the balloon port to obtain the sterile specimen would deflate the balloon that holds the catheter in place and cause trauma to the bladder wall.
Normal ranges for urine characteristics vary depending on the type of analysis, but some general parameters are:
• Color: pale yellow to amber
• Clarity: clear or slightly cloudy
• Odor: faint aromatic
• pH: 4.5 to 8.0
• Specific gravity: 1.005 to 1.030
• Protein: <150 mg/24 hr
• Glucose: negative
• Ketones: negative
• Blood: negative
• Nitrites: negative
• Leukocyte esterase: negative
• Bacteria: <10,000 CFU/mL
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