A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?

Release the client's restraints every 4 hr.

Check the client's status every hour.

Document the client's behavior leading to the initiation of the restraints.

Obtain written consent by the client for the placement of the restraints.

Release the client's restraints every 4 hr.

Check the client's status every hour.

Document the client's behavior leading to the initiation of the restraints.

Obtain written consent by the client for the placement of the restraints.

Answer and Explanation

The Correct Answer is C

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.

B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.

C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.

D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.

A. Conduct change-of-shift report near the clients' rooms. B. Turn on overhead lights briefly when checking IV lines. C. Open curtains between clients in semiprivate rooms. D. Wear shoes with rubber soles.

Correct Answer is D

Explanation

Wearing shoes with rubber soles can minimize noise and provide a quieter environment for the clients. It helps reduce disruptions caused by footsteps, especially during nighttime when clients are trying to sleep.

Conducting change-of-shift report near the clients' rooms can lead to increased noise levels and disturb clients' sleep. It is best to conduct report in a designated area away from patient rooms to minimize disruptions.

Overhead lights should be avoided during nighttime or sleep hours as they are bright and can disrupt a client's sleep. Instead, nurses should use a low-intensity light or a flashlight to check IV lines or attend to other needs. This helps minimize disruptions to the client's rest.

Opening curtains between clients in semiprivate rooms can compromise privacy and contribute to increased noise levels. It is important to provide privacy for clients, especially during their rest periods.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Correct Answer is C

Explanation

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?