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.

Answer and Explanation

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 A

Explanation

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.

A. A client who has a history of MRSA will need antibiotics. B. A client who has a history of MRSA can develop immunity to the infection. C. A client who has a history of MRSA requires a protective environment. D. A client who has a history of MRSA can still transmit the infection.

Correct Answer is D

Explanation

A. Not all clients with a history of MRSA will require antibiotics. Treatment depends on the presence of active infection, colonization, and other clinical factors.
B. There is no evidence to suggest that individuals can develop immunity to MRSA. MRSA remains a significant pathogen, and individuals with a history of MRSA remain susceptible to reinfection or colonization.
C. A protective environment is not typically required for clients with a history of MRSA. Standard precautions, including hand hygiene and appropriate use of personal protective equipment, are sufficient to prevent transmission.

D. Clients with a history of MRSA can still carry the bacteria on their skin or in their nasal passages and may transmit the infection to others, especially in healthcare settings. Therefore, it is important to adhere to infection control practices to prevent transmission.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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