A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?
Request a PRN restraint prescription for clients who are aggressive.
Document the client's condition every 15 min.
Attach the restraint to the bed's side rails.
Remove the client's restraint every 4 hr.
The Correct Answer is B
Answer is: b. Document the client's condition every 15 min.
Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.
Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.
Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.
Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Documenting the desire to be an organ donor in writing is a legal requirement and ensures that the individual's wishes are respected after their passing. It also provides clear guidance to healthcare providers and family members about the individual's decision.
Choice B rationale:
There is no specific age requirement to become an organ donor. People of various ages can register as organ donors, and eligibility often depends on the condition of the organs at the time of death.
Choice C rationale:
Once someone is listed as an organ donor, their name can be removed if they change their mind. It's essential for individuals to inform their family members about their decision and ensure their wishes are respected.
Choice D rationale:
The nurse can indeed be a witness for the consent to donate. Being a witness ensures the authenticity of the individual's decision to become an organ donor and can be helpful in legal and ethical contexts.
Correct Answer is D
Explanation
Choice A rationale:
Taking antibiotics when having a virus is not a correct understanding of infection prevention. Antibiotics are ineffective against viruses and should only be used for bacterial infections under the guidance of a healthcare provider. This statement indicates a misunderstanding of infection prevention.
Choice B rationale:
Washing hands for at least 20 seconds with soap and water is the recommended practice for infection prevention. Washing hands for 10 seconds may not be sufficient to remove all germs effectively. This statement does not demonstrate a proper understanding of hand hygiene.
Choice C rationale:
Cleaning a cat's litter box during pregnancy is not recommended due to the risk of contracting toxoplasmosis, a parasitic infection that can harm the fetus. Pregnant individuals should avoid handling cat litter to prevent exposure to this infection. This statement indicates a lack of awareness regarding infection prevention during pregnancy.
Choice D rationale:
Waiting 5 days after the chickenpox sores have crusted before visiting a person with chickenpox demonstrates an understanding of infection prevention. Chickenpox is highly contagious, and individuals should avoid close contact until the sores have fully healed and crusted over. This statement reflects appropriate knowledge about preventing the spread of contagious diseases during pregnancy.
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