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A nurse is providing teaching to assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
- A. Secure the client's restraints with a square knot.
- B. Attach the restraints to the fixed portion of the frame of the client's bed.
- C. Remove the client's restraints every 2 hr.
- D. Allow 1 fingerbreadth between the restraint and the client's wrists.
Correct Answer: C
Rationale: The correct answer is C: Remove the client's restraints every 2 hr. This instruction is crucial to prevent complications such as skin breakdown, circulation impairment, and emotional distress. Restraints should be released every 2 hours to assess the client's condition, provide necessary care, and ensure safety. This practice also promotes mobility and prevents long-term consequences of prolonged restraint use.
Explanation for other choices:
A: Secure the client's restraints with a square knot - Incorrect. Restraints should be secured with a quick-release knot to ensure quick removal in case of an emergency.
B: Attach the restraints to the fixed portion of the frame of the client's bed - Incorrect. Restraints should be attached to the movable portion of the bed frame to allow for adjustments and prevent harm.
D: Allow 1 fingerbreadth between the restraint and the client's wrists - Incorrect. Restraints should be snug but not too tight to avoid injury or discomfort.
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Exhibit 1 Nurses' Notes 1315:
Client is postoperative following an open cholecystectomy, Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment
Plan of Care
1300:
Case management referral for discharge planning.
Client will need home health referral for dressing changes Client to follow up with the provider at the clinic in 1 week.
A nurse case manager is reviewing the electronic medical record of a postoperative client. Click to highlight the findings that require follow-up by the case manager.
- A. Client reports being unable to find transportation to follow-up appointment
- B. Client expresses concern regarding the cost of prescription medications
- C. Case management referral for discharge planning
- D. Client will need home health referral for dressing changes
Correct Answer: A
Rationale: []
Rationale:
- Correct Answer (A): The client reporting being unable to find transportation to the follow-up appointment is a critical issue that requires immediate follow-up by the case manager to ensure continuity of care and adherence to the treatment plan.
- Incorrect Answer (B): Although concerns about the cost of prescription medications are important, they do not directly relate to the immediate follow-up needed postoperatively.
- Incorrect Answer (C): Case management referral for discharge planning is essential but does not specifically address the immediate follow-up after the postoperative period.
- Incorrect Answer (D): While the client needing a home health referral for dressing changes is important, it does not pertain to the immediate follow-up that the case manager needs to address.
Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?
- A. Use clean gloves rather than sterile gloves for colostomy care.
- B. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
- C. Return unused supplies from the bedside to the unit's supply stock.
- D. Wait to dispose of sharps containers until they are completely full.
Correct Answer: C
Rationale: The correct answer is C: Return unused supplies from the bedside to the unit's supply stock. This action helps reduce waste by ensuring that supplies are not being unnecessarily discarded. By returning unused supplies, the unit can minimize unnecessary expenditures on restocking items that could have been used if properly managed. Additionally, it promotes efficient resource utilization and cost savings by preventing duplicate purchases.
Incorrect choices:
A: Using clean gloves rather than sterile gloves for colostomy care may compromise patient safety and increase the risk of infection.
B: Storing opened bottles of normal saline in a refrigerator for up to 48 hours may lead to contamination and compromise patient safety.
D: Waiting to dispose of sharps containers until they are completely full may increase the risk of needle-stick injuries and pose safety hazards.
A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?
- A. Request the client sign an informed consent.
- B. Encourage the client to reconsider their decision
- C. Communicate the client's decision to the provider.
- D. Provide care for the client using a sympathetic approach.
Correct Answer: C
Rationale: The correct answer is C: Communicate the client's decision to the provider. This is the most appropriate action as it ensures the client's wishes are respected while also involving the healthcare provider in the decision-making process. By communicating the client's decision, the nurse is upholding the client's autonomy and promoting patient-centered care. Option A is incorrect as the client's refusal of chemotherapy does not require informed consent. Option B is inappropriate as it undermines the client's autonomy by pressuring them to reconsider. Option D is not the best choice as it focuses on the nurse's approach rather than facilitating communication between the client and the provider.
A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?
- A. A young adult client who is participating in a medical research study
- B. A middle adult client who leaves the facility against medical advice
- C. An adolescent client whose parents refuse a blood transfusion for religious reasons.
- D. An older adult client who has advance directives on file
Correct Answer: C
Rationale: Parental refusal of a blood transfusion for a minor creates an ethical dilemma, balancing autonomy and the minor's health, requiring ethics committee input.
A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
- A. Contact the case manager to discuss discharge options.
- B. Request another family member assist the client's partner with care.
- C. Ask the provider to delay the client's discharge home for a few more days.
- D. Recommend the partner place the client in a long-term care facility.
Correct Answer: A
Rationale: A case manager can explore alternative care options, such as home health or facility placement, to support the client and partner.