A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)
The provider should renew the prescription for restraints every 48 hr.
The nurse should pad the bony prominences.
The nurse should tie the restraints using a square knot.
The nurse should remove the restraints every 2 hr.
The provider's prescription should include the type of restraint to use.
Correct Answer : B,D,E
A. The provider should renew the prescription for restraints every 24 hours, not 48 hours. This ensures regular evaluation of the need for continued restraint use.
B. Padding bony prominences helps prevent skin breakdown and injury from the restraints.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in case of emergency.
D. Restraints should be released every 2 hours (or as specified by the provider) to assess and provide care for the client's needs and to prevent complications such as skin breakdown or circulation impairment.
E. The provider's prescription should specify the type of restraint to be used, the reason for use, the duration, and any other relevant details to ensure appropriate and safe application.
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Correct Answer is D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needlestick injuries and is not recommended.
B. Placing broken glass in a wastebasket increases the risk of injury to housekeeping staff; it should be disposed of in a puncture-proof container.
C. Recapping needles increases the risk of needlestick injuries and is not recommended unless there are no alternatives available.
D. Placing lancets in a puncture-proof container is the correct procedure for preventing puncture injuries, as it safely contains sharp objects and reduces the risk of accidental needlesticks.
Correct Answer is C
Explanation
A. Dependent edema can occur with pericarditis but does not indicate an immediate life-threatening complication.
B. A pericardial friction rub is a common finding in pericarditis and helps confirm the diagnosis but is not the priority.
C. A paradoxical pulse (an exaggerated decrease in systolic blood pressure during inspiration) is a sign of cardiac tamponade, a life-threatening complication of pericarditis, and requires immediate intervention.
D. Substernal chest pain is expected with pericarditis and is usually relieved by sitting up and leaning forward, but it is not the most urgent concern.
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