Which nursing intervention should be performed before applying client restraints?

Visual inspection of skin for placement.

Positioning for proper body alignment.

Assess the need for restraints placement.

Review facility policy before usage.

Answer and Explanation

The Correct Answer is C

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.

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Correct Answer is B

Explanation

Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.

The Z-track method is a technique used to administer intramuscular injections that prevent leakage of medication into the subcutaneous tissue. The nurse should pull the skin laterally before inserting the needle, inject the medication slowly, leave the needle in place for at least 10 seconds, and release the skin after withdrawing the needle.

Choice A is wrong because the total volume of the injection is not limited to 1 milliliter in the Z-track method. The Z-track method can be used to administer up to 3 milliliters of medication depending on the site and muscle mass of the client.

Choice C is wrong because the needle size and gauge depend on the site, medication, and client characteristics, not on the Z-track method. The Z-track method can be performed with different needle sizes and gauges as long as they are appropriate for intramuscular injections.

Choice D is wrong because the nurse should not administer the medication rapidly in the Z- track method.

Rapid injection can cause pain, tissue damage, and leakage of medication into the subcutaneous tissue. The nurse should inject the medication slowly and steadily in the Z-track method.

A. TMS requires anesthesia prior to administration. B. TMS requires a muscle relaxing medication prior to administration. C. TMS requires the patient to lay flat in bed during administration. D. TMS requires daily treatments for 4 to 6 weeks.

Correct Answer is D

Explanation

TMS requires daily treatments for 4 to 6 weeks. This is because TMS is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. TMS is typically used when other depression treatments haven’t been effective. The treatment can last 30 to 60 minutes and is done 5 days a week for about 4 to 6 weeks.

Choice A is wrong because TMS does not require anesthesia prior to administration. The procedure is done without using surgery or cutting the skin and the patient is awake throughout the treatment.

Choice B is wrong because TMS does not require a muscle-relaxing medication prior to administration. The procedure does not cause muscle contractions or spasms and the patient can resume normal activities after the treatment.

Choice C is wrong because TMS does not require the patient to lay flat in bed during administration. The procedure is done in a comfortable chair and the patient can drive themselves home after the treatment.

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Which nursing intervention should be performed before applying client restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should a nurse perform when administering an intramuscular injection via the Z- track method?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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