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 B
Explanation
The correct answer is b. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
Choice A rationale:
- Statement:“I should take antibiotics when I have a virus.”
- Rationale:This statement is incorrect.Antibiotics are medications that fight bacteria,not viruses.Taking antibiotics when you have a virus will not help you get better and can actually lead to antibiotic resistance.
Choice B rationale:
- Statement:“I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
- Rationale:This statement is correct.Chickenpox is a highly contagious virus that is spread through the air by coughing and sneezing.However,a person with chickenpox is no longer contagious once all of the sores have crusted over.This typically happens about 5 days after the rash first appears.
Choice C rationale:
- Statement:“I should wash my hands for 10 seconds with hot water after working in the garden.”
- Rationale:This statement is partially correct.Handwashing is an important way to prevent the spread of infection.However,the water does not need to be hot.Warm or cold water is just as effective.It is also important to wash your hands for at least 20 seconds,not 10 seconds.
Choice D rationale:
- Statement:“I can clean my cat’s litter box during my pregnancy.”
- Rationale:This statement is incorrect.Cat feces can contain a parasite called Toxoplasma gondii,which can cause a serious infection called toxoplasmosis.Toxoplasmosis can be harmful to a developing baby.It is best to avoid cleaning cat litter boxes during pregnancy.If you must clean the litter box,wear gloves and wash your hands thoroughly afterwards.
Correct Answer is C
Explanation
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:
- Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
- High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
- Unpasteurized juice, milk, yogurt, or cheese
- Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
Choice A is wrong because popcorn is a choking hazard for toddlers.
It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
Choice B is wrong because grapes are also a choking hazard for toddlers.
They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
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