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A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr.
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rail.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to ensure the safety and well-being of the client in restraints. Documenting the client's condition frequently allows for timely identification of any signs of distress, discomfort, or complications related to the use of restraints. This practice helps in monitoring the client's physical and psychological status, enabling prompt intervention if necessary.
Removing the client's restraint every 4 hours (choice A) is incorrect as it may compromise the client's safety and increase the risk of injury or harm. Requesting a PRN restraint prescription for aggressive clients (choice C) is inappropriate as restraints should only be used as a last resort and not for convenience. Attaching the restraint to the bed's side rail (choice D) is unsafe and restricts the client's movement unnecessarily.
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A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.'
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.'
- C. It's okay to be nervous before this treatment.'
- D. You don't have to go through with the treatment.'
Correct Answer: D
Rationale: Correct Answer: D. "You don't have to go through with the treatment."
Rationale: This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's change of mind and supports their decision-making process without pressuring them. It is important for healthcare providers to prioritize patient autonomy and respect their choices.
Other Choices:
A: Incorrect. This statement may invalidate the client's feelings and pressure them to proceed with the treatment.
B: Incorrect. This statement undermines the client's autonomy by implying that the doctor's decision is more important than the client's own preferences.
C: Incorrect. While acknowledging nervousness is appropriate, it does not address the client's change of mind and decision to not proceed with the treatment.
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
A nurse is planning to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning.
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is essential as it considers the client's level of participation and promotes independence. Assessing the client's ability to assist ensures safety and prevents injury during repositioning. It also promotes client-centered care by involving the client in their own care.
Choice B is incorrect because repositioning without assistive devices may not be safe or effective, especially for a stroke client who may have limited mobility.
Choice C is incorrect because raising the side rails does not address the client's ability to help with repositioning. It may provide some safety measures but does not actively involve the client in the process.
Choice D is incorrect as discussing preferences for a repositioning schedule does not address the immediate need to evaluate the client's ability to assist with repositioning.
Overall, choice A is the most appropriate as it prioritizes the client's safety, independence, and active participation in their care.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C because removing constrictive clothing prior to measuring blood pressure helps ensure accurate readings. Tight clothing can artificially elevate blood pressure readings. Choice A is incorrect because waiting 15 minutes after drinking coffee doesn't impact blood pressure measurement accuracy. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect because blood pressure should be measured on an empty stomach for consistency.
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
- A. Increase the amount of refined grains in the client's diet.
- B. Provide the client with a cold drink prior to defecation.
- C. Administer a cathartic suppository 30 min prior to scheduled defecation times
- D. Encourage a maximum fluid intake of 1,500 mL per day.
Correct Answer: C
Rationale: The correct answer is C: Administer a cathartic suppository 30 min prior to scheduled defecation times. This action helps stimulate bowel movement in clients with spinal cord injuries by promoting peristalsis and aiding in bowel evacuation. Increasing refined grains (choice A) may not directly address the bowel-training program. Providing a cold drink (choice B) may not have a significant impact on bowel movements. Restricting fluid intake to 1,500 mL per day (choice D) can lead to dehydration and worsen constipation.