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 C
Explanation
The correct answer is:
Choice C: Determine the medical needs of incoming clients through the emergency department.
Here's a breakdown of the rationale for each choice:
Choice A rationale: While calling in additional staff might be helpful in the long run, during the initial surge of patients in a mass casualty event, the Emergency Department (ED) will be the primary area receiving and triaging patients. The medical-surgical unit will likely receive overflow patients after initial stabilization in the ED.
Choice B rationale: This is not a primary responsibility for a nurse on a medical-surgical unit during a mass casualty event. Communication with the media is usually handled by designated public relations personnel.
Choice C rationale: This is the most crucial action for a nurse in this situation. Triaging patients based on the severity of their injuries and prioritizing care is essential in a mass casualty scenario. Nurses will be instrumental in assessing incoming patients relayed from the ED to determine their medical needs and allocate resources accordingly.
Choice D rationale: Discharging patients is not a priority during the initial influx of casualties. The focus is on receiving, stabilizing, and treating the most critically injured patients. Discharges would likely happen after the initial surge subsides.
Correct Answer is B,D,A,C
Explanation
B. Review the skill level and qualifications of each AP.
Before delegating tasks, the nurse should assess the skill level and qualifications of each AP to ensure they have the necessary knowledge and training to perform the assigned tasks safely and effectively.
D. Communicate appropriate tasks to the APs with specific expectations.
The nurse should clearly communicate the tasks to be delegated to each AP. This includes providing specific instructions, expectations, and any necessary information to ensure the APs understand what is expected of them and can perform the tasks correctly.
A. Monitor progress of task completion with each AP.
Once the tasks are assigned, the nurse should periodically check in with each AP to monitor the progress of task completion. This allows the nurse to provide support, answer questions, and ensure that tasks are being performed as expected.
C. Evaluate the APs' performance of each task.
After the tasks are completed, the nurse should evaluate the APs' performance of each task. This evaluation helps identify any areas for improvement, additional training needs, and overall competency of the APs.
Delegating tasks to assistive personnel is an essential aspect of nursing practice. Following this sequence of steps helps ensure that tasks are delegated appropriately and that the care provided is safe, efficient, and aligned with the APs' capabilities. Regular communication and feedback are essential to effective task delegation and teamwork within the healthcare setting.
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