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. "I should use chairs without armrests.": Armrests provide support during transfers and help prevent falls.
B. "I should place a throw rug over electrical cords.": Rugs over cords increase the risk of tripping.
C. "I should get a longer cord for my telephone.": Longer cords can become a tripping hazard.
D. "It is a good idea to use the handrails in the bathroom.": Handrails promote safety and stability, especially in bathrooms where falls are common.
Correct Answer is ["A","B","D","E"]
Explanation
A. Elevate the bed to waist height: Raising the bed to waist level promotes proper body mechanics and reduces back strain for caregivers.
B. Position the client toward the edge of the bed on the side the client will face after turning: This makes repositioning easier and safer, allowing for better leverage and control.
C. Remove pillows prior to repositioning: Pillows may support body parts during turning and should be removed only if they obstruct repositioning, not as a general rule.
D. Stand with their feet wide apart: A wide base of support ensures better balance and stability when repositioning a client.
E. Face the direction of movement when repositioning the client: Facing the direction of movement maintains spinal alignment and prevents twisting injuries.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.