Nurse observed client attempting to pull out IV line and urinary catheter. Attempts made to reorient and calm client are unsuccessful. Instructed assistant personnel to stay with client. Placed call to provider and family. Return call from provider, update given. Prescription received for soft wrist restraints. Please complete the sentence based off of your understanding of restraints.
Complete the following sentence by using the list of options.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Rationale for correct answers:
a) Apply soft wrist restraints with assistance:
The nurse has already received a prescription from the provider for restraints due to the client actively attempting to remove medical devices. This makes the restraint medically justified and legally authorized. The restraints should be applied safely and with assistance to prevent injury during application.
c) Document the restraint application, reason, and patient response in the record:
Documentation is a legal and professional responsibility. It ensures the rationale, time, condition, interventions attempted before restraints, and client response are recorded clearly.
Rationale for incorrect answers:
b) Administer pain medication for agitation:
No indication in the note suggests pain as the cause of agitation. Medication without cause or order for agitation is inappropriate.
c) Notify the family of the restraint application:
While notifying the family is appropriate and often done, it is not the first or immediate priority once the restraint order is in place and the client is at risk of self-harm.
a) Notify charge nurse and ask for sitter assignment:
This is a helpful support measure, but after applying the restraints and documenting the care. It does not take precedence over immediate client safety and legal documentation.
b) Remove the catheter and IV to prevent further injury:
This would violate the standard of care unless ordered by the provider. The correct action is to prevent removal by using restraints safely and legally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Place the client in a modified Trendelenburg position: This may help with shock after bleeding is controlled, but is not the first action.
B. Apply a tourniquet just above the wound: Tourniquets are a last resort when direct pressure fails to control bleeding.
C. Elevate the extremity: Elevation can help reduce bleeding, but only after direct pressure is applied.
D. Apply pressure directly to the wound: This is the first-line intervention to control bleeding in most cases.
Correct Answer is D
Explanation
A. "I'll put a heating pad on my ankle at bedtime tonight.": Heat is contraindicated in the first 24–48 hours of a sprain due to increased risk of swelling and bleeding.
B. "I'll walk on my ankle for 10 minutes every hour.": Weight-bearing should be minimized in the acute phase of a sprain.
C. "I'll rewrap my ankle starting from the knee down.": Wrapping should begin at the toes and go upward to promote venous return.
D. "I'll apply ice to my ankle for 20 minutes every hour.": Ice therapy helps reduce swelling and pain and should be applied 20 minutes at a time, typically every 1 to 2 hours during the first 24–48 hours.
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