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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation: Yellow patches in the mouth are an indication of oral candidiasis, also known as thrush, which is a fungal infection caused by Candida albicans. Oral candidiasis can cause symptoms such as pain, burning, redness, and difficulty swallowing in addition to yellow patches on the tongue, palate, cheeks, or throat. Hearing loss, night sweats, and
brittle nails are not manifestations of candida infection.
Correct Answer is A
Explanation
Choice A rationale:
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.
Choice B rationale:
Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.
Choice C rationale:
Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.
Choice D rationale:
Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.
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