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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
To find the rate of the pump in ml/hour, you need to first convert the client’s weight from pounds to kilograms. You can do this by dividing the weight by 2.2046 or multiplying it by 0.454.
For example:
297 lbs / 2.2046 = 134.72 kg or 297 lbs x 0.454 = 134.72 kg
Then, you need to multiply the client’s weight in kilograms by the ordered dose in units/kg/hour to get the total units per hour.
For example:
134.72 kg x 12 units/kg/hour = 1616.64 units/hour
Next, you need to set up a proportion to find the rate of the pump in ml/hour using the supplied medication concentration.
For example:
25,000 units / 500 ml = 1616.64 units / X ml Cross-multiply and solve for X:
25,000 x X = 808320 X = 808320 / 25000 X = 32.33 ml/hour
Finally, you need to round your answer to the nearest tenth of a ml/hour as per the medication administration guidelines.
For example:
32.33 ml/hour ≈ 32.3 ml/hour
Therefore, the rate of the pump is 32.3 ml/hour.
Choice A is wrong because it uses a different conversion factor for pounds to kilograms (1 lb = 0.5 kg) which is not accurate.
Choice C is wrong because it uses a different ordered dose (10 units/kg/hour) which is not what the provider has written.
Choice D is wrong because it uses a different supplied medication concentration (20,000 units in 500 ml) which is not what is available.
Correct Answer is C
Explanation
I’d like to hear what you are thinking.” This response by the nurse would most likely prompt the client to elaborate on their concerns because it acknowledges the uncertainty of the situation and invites the client to share their feelings and thoughts.
It also shows empathy and respect for the client’s perspective.
Choice A is wrong because it may give false reassurance or minimize the client’s anxiety. Biopsies are not always negative and the nurse cannot predict the outcome.
Choice B is wrong because it may imply that the nurse is avoiding the question or shifting the responsibility to the health care provider.
It also does not address the client’s emotional state or encourage communication.
Choice D is wrong because it may dismiss the client’s fears or imply that they are irrational. It also does not explore the client’s understanding of the procedure or the possible results.
A uterine biopsy is a procedure that involves removing a small piece of tissue from the lining of the uterus (endometrium) for examination under a microscope. It is usually done to diagnose abnormal bleeding, infections, or cancer. The normal range of endometrial thickness varies depending on the menstrual cycle, age, and hormonal status of the woman.
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.