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 C

Explanation

Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss. Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.

Choice A is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.

Choice B is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.

Choice D is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.

Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults. Normal ranges for heart rate are 60 to 100 beats per minute for adults.

A. “A nurse will draw blood from your baby’s inner elbow.” B. “Your baby will be given 2 ounces of water to drink prior to the test.” C. “This test will be repeated when your baby is 2 months old.” D. “This test should be performed after your baby is 24 hours old.”

Correct Answer is D

Explanation

This test should be performed after your baby is 24 hours old. This is because newborn genetic screening is a set of laboratory tests that detect a set of known genetic diseases that can affect a child’s long-term health or survival. The test is performed on a blood sample obtained from a heel prick when the baby is two or three days old. Performing the test after 24 hours ensures that the baby has had enough time to metabolize certain substances that could interfere with the accuracy of the test.

Choice A is wrong because the blood sample is not drawn from the baby’s inner elbow, but from the heel.

Choice B is wrong because the baby does not need to drink water prior to the test, as this could dilute the blood sample and affect the results.

Choice C is wrong because the test does not need to be repeated when the baby is 2 months old, unless there is a positive or inconclusive result from the first test.

Newborn genetic screening is important for early detection and intervention of certain conditions that can cause serious health problems or disability if left untreated. Parents should be informed about the benefits and limitations of the test, as well as their rights and options regarding consent and confidentiality.

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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 assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

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