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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 1 cm of water present in the water seal chamber is within the expected range.
B. Tidaling with spontaneous respirations indicates the system is functioning properly.
C. Suction chamber pressure of -20 cm H2O is within the expected range for adequate suction.
D. The drainage collection chamber being one-third full suggests an accumulation of fluid beyond the expected level, which may indicate a potential complication such as hemorrhage or fluid buildup in the pleural space, requiring intervention by the nurse.
Correct Answer is C
Explanation
A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.
B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.
C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.
D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.
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