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 B

Explanation

Dabigatran is a blood thinner that is used to prevent strokes or blood clots in people with atrial fibrillation, a type of irregular heartbeat. Dabigatran is sensitive to moisture and can lose its potency if exposed to humidity or heat. Therefore, it is important to store it in the original bottle or blister package that has a desiccant (drying agent) in the cap or cover. The client should also close the cap tightly after each use and keep the bottle away from excessive moisture, heat, and cold.

Choice A is wrong because storing the medication in the refrigerator can expose it to moisture and cause it to break down.
Choice C is wrong because crushing the medication and mixing it with applesauce can alter its absorption and effectiveness.
Choice D is wrong because the medication can be used up to 60 days after opening the bottle as long as it is stored properly. The normal dose of dabigatran for stroke prevention in atrial fibrillation is 150 mg twice a day unless the client has kidney problems or other factors that require a lower dose.

A. Drooling. B. Tinnitus. C. Malaise. D. Rhinorrhea. E. Rhinorrhea.

Correct Answer is C

Explanation

Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing. Malaise is one of the symptoms that may follow these signs of infection.

Choice A is wrong because it is not a typical symptom of bacterial pneumonia.

Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.

Choice B is wrong because it is not a symptom of bacterial pneumonia either.

Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.

Choice D is wrong because it is not specific to bacterial pneumonia.

Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.

Rhinorrhea can sometimes occur with viral pneumonia, but not usually with bacterial pneumonia.

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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 teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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