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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Levothyroxine is a thyroid hormone replacement medication commonly used to treat hypothyroidism. It is not associated with teratogenic effects when used appropriately.
B. Phenytoin is an anticonvulsant medication that is known to be teratogenic, especially when used during the first trimester of pregnancy. It is associated with an increased risk of congenital malformations, such as cleft palate and heart defects, in infants born to mothers who take the medication during pregnancy.
C. Magnesium oxide is a mineral supplement commonly used to treat constipation during pregnancy. It is not associated with teratogenic effects when used appropriately.
D. Ferrous sulfate is an iron supplement commonly used to treat chronic anemia during pregnancy. It is not associated with teratogenic effects when used appropriately.
Correct Answer is A
Explanation
A.
A. Asymmetric lesions with variegated (multiple) colors are characteristic features of melanoma, a type of skin cancer. Asymmetry means one half of the lesion does not match the other half in size, shape, or color.
B. Scaly and red lesions may indicate other skin conditions such as eczema or psoriasis but are not specific to skin cancer.
C. Brown lesions with a wart-like texture may indicate seborrheic keratosis, a benign skin growth, rather than skin cancer.
D. Firm and rubbery lesions may indicate benign skin tumors such as fibromas or lipomas, rather than skin cancer.
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