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
The Correct Answer is A
When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:
A) Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.
Some of the other choices are wrong because:
- Choice A. Supervise return demonstration of diaphragm use.
This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.
- Choice C. Document the client’s level of understanding about potential adverse effects.
This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.
- Choice D. Teach the client how to insert the diaphragm.
This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.
A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.
It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.
It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.
Correct Answer is A
Explanation
The correct answer is A. Beneficence. Beneficence is the ethical principle of doing good for the patient and promoting their well-being.
The nurse is demonstrating beneficence by sitting with the client to provide comfort and support during a difficult time.
Choice B is wrong because fidelity is the ethical principle of keeping promises to the patient and being loyal and faithful.
The nurse is not making or keeping any promises to the client in this scenario.
Choice C is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own decisions and choices.
The nurse is not interfering with the client’s autonomy in this scenario.
Choice D is wrong because veracity is the ethical principle of telling the truth to the patient and being honest and trustworthy.
The nurse is not lying or withholding information from the client in this scenario.
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