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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B: Wear a surgical mask when within 0.9 m (3 feet) of the client.

Choice A rationale:

Fresh flowers are generally discouraged in hospital settings for clients with compromised immune systems due to the risk of infection from soil or water, which can harbor harmful microorganisms. However, this is not specifically related to rubella, which is an airborne virus.

Choice B rationale:

Rubella is transmitted through airborne droplets when an infected person coughs or sneezes. Wearing a surgical mask when close to the client can help prevent the spread of the virus. This is especially important to protect individuals who are pregnant or may become pregnant, as rubella can cause serious birth defects.

Choice C rationale:

Negative-airflow pressure rooms are used for clients with airborne infections, such as tuberculosis. While rubella is also airborne, the current guidelines do not require a negative pressure room for its management.

Choice D rationale:

While limiting visitors can help control the spread of infection, it is not the primary action to take for a client with rubella. The focus should be on preventing the spread through droplet transmission, which is addressed by wearing a mask and practicing good hand hygiene.

A. Request a provider to evaluate the client in person every 36 hr. B. Document the client's behavior every 15 min. C. Ensure that the prescription for restraints be renewed every 6 hr. D. Plan to monitor the client every 30 min while restrained.

Correct Answer is B

Explanation

Choice A rationale:

Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.

Choice B rationale:

Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.

Choice C rationale:

Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.

Choice D rationale:

Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.

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A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

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A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?