The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her
wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse manager?

Contact the healthcare provider to ensure that a prescription for restraints was written.

Advise the staff nurse to remove the restraints from the client's wrists.

Close the door to the room to avoid disturbing other clients in nearby rooms.

Determine if the client has an as needed (PRN) prescription for an antianxiety agent

Answer and Explanation

The Correct Answer is B

Choice A Reason: Contacting the healthcare provider is not the priority action because restraints should only be used as a last resort and not for staff convenience. The nurse manager should first ensure that the client's safety and dignity are respected.

Choice B Reason: This is the correct answer because restraints are not indicated for this situation and violate the client's rights. The nurse manager should educate the staff nurse about the ethical and legal implications of using restraints without proper justification and documentation.

Choice C Reason: Closing the door to the room is not a priority action because it does not address the issue of restraints. It also may isolate the client and increase her anxiety and distress.

Choice D Reason: Determining if the client has a PRN prescription for an antianxiety agent is not a priority action because it does not address the issue of restraints. It also may not be appropriate to medicate the client without assessing her condition and obtaining her consent.

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Correct Answer is B

Explanation

Choice A Reason: Asking the client why he does not want to be weighed is not a priority action because it does not address the need to obtain his daily weight. The nurse should first try to find a way to weigh the client without causing him discomfort or distress.

Choice B Reason: This is the correct answer because weighing the client using a bed scale can avoid the need for

transferring him from the bed to a standing scale, which may be difficult or painful for him. The bed scale can provide an accurate measurement of his weight and help monitor his fluid status.

Choice C Reason: Directing the UAP to delay weighing the client until later is not an appropriate action because it may result in missing or inaccurate data. The nurse should ensure that the client is weighed at the same time every day, preferably in the morning, before any fluid intake or output.

Choice D Reason: Documenting that the client refused daily weights is not an adequate action because it does not reflect the nurse's responsibility to provide quality care for the client. The nurse should try to resolve the issue of weighing the client and documenting the outcome and any interventions.

A. Call the hospital operator to determine if this is indeed a real emergency or a fire drill. B. Instruct the clients' family members to stay in the visitor waiting area until further notice. C. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. D. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

Correct Answer is D

Explanation

Choice A Reason: This action is not a priority, as it may delay the response to a potential fire. The charge nurse should assume that the fire alarm is real and act accordingly.

Choice B Reason: This action may expose the clients' family members to smoke or fire, as the visitor waiting area may not be safe. The charge nurse should ensure that everyone is in a protected area.

Choice C Reason: This action may be dangerous, as the stairs may be filled with smoke or fire. The charge nurse should follow the hospital's fire safety protocol, which usually involves closing doors, windows, and vents to prevent the spread of fire.

Choice D Reason: This action is the most appropriate, as it follows the RACE acronym for fire safety: Rescue anyone in immediate danger, Alarm by activating the fire alarm system, Contain by closing doors and windows, and Extinguish or evacuate as directed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

Correct Answer is B

Explanation

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

Correct Answer is D

Explanation

The nurse determines that an elderly client with pneumonia has a nursing problem of "altered nutrition, less than body requirements." Which instruction should the nurse give the unlicensed assistive personnel (UAP) helping with the care of this client?

The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?

Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?

A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?

To help prevent by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will

The nurse determines that an IV vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)