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
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention. Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism. The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is well- controlled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A.
Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
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.
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