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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

- A: An INR of 1.1 is within the normal range, indicating normal blood clotting ability, which is essential for wound healing. A normal INR does not pose a risk for delayed wound healing.
- B: Hyperemesis can lead to dehydration and malnutrition, both of which are detrimental to wound healing. Dehydration reduces blood volume and flow, impairing the delivery of oxygen and nutrients to the wound site, while malnutrition can weaken the immune response and the formation of new tissue.
- C: An HbA1C level of 5.6% is at the high end of the normal range and does not typically indicate diabetes or impaired glucose control, which are risk factors for delayed wound healing.
- D: While uncontrolled pain can be a concern for patient comfort and may indirectly affect wound healing by reducing mobility, it is not a direct risk factor for delayed wound healing like hyperemesis is.

A. A child who has a forehead wound that is bleeding copiously B. A child who has a compound fracture of the femur and is crying in pain C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip

Correct Answer is C

Explanation

A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.

B. A child who has a compound fracture of the femur and is crying in pain: While painful, a

femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.

C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:

These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.

D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.

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

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

A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?

Correct Answer is B

Explanation

An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first?

Correct Answer is C

Explanation

A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant?

A nurse is providing teaching to the parent of a 6-month-old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include?

A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take?

A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?

A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation?

A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects?

A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?