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The nurse is caring for a client who repeatedly attempts to get up from their wheelchair unassisted and has fallen twice. The primary healthcare provider (PHCP) prescribes restraints. Which type of restraint does the nurse anticipate?
- A. Soft wrist restraints
- B. Mitten restraints
- C. Seclusion
- D. Waist belt restraint
Correct Answer: D
Rationale: A waist belt restraint prevents unassisted standing while allowing some mobility. Wrist or mitten restraints limit hand use, and seclusion is inappropriate for fall prevention.
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The charge nurse is reviewing room assignments and recognizes that only one private room is left. It would be appropriate to assign this room to the client with
- A. Human immunodeficiency virus (HIV).
- B. Delirium tremens who is agitated.
- C. Disseminated herpes zoster.
- D. An implantable port that is accessed.
Correct Answer: C
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a private room. HIV, delirium tremens, and accessed ports do not require isolation.
The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.
The nurse is performing a home safety assessment for an older adult. Which intervention would be appropriate for the nurse to recommend to reduce the client's risk of falling?
- A. Installation of non-slip mats in the kitchen
- B. Placement of furniture in the center of rooms
- C. Remove locks from doors
- D. Painting walls with bright colors
Correct Answer: A
Rationale: Non-slip mats reduce fall risk by improving traction. Furniture placement, door locks, and wall color do not directly address falls.
The nurse supervises a student assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
- A. Puts the client's affected (weaker) arm in the shirt's sleeve first.
- B. Places shoes with velcro straps on the client's feet.
- C. Places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
- D. Places the hairbrush in the client's unaffected (stronger) hand.
Correct Answer: C
Rationale: Wheelchair on the affected side hinders transfer; it should be on the unaffected side. Dressing the weaker arm first, velcro shoes, and stronger hand use are correct.
Which of the following statements about security in healthcare environments is accurate?
- A. Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility.
- B. All members of the healthcare facility must have education and training relating to security in the facility.
- C. Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility.
- D. Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility.
Correct Answer: B
Rationale: All healthcare staff, regardless of role, require security training to ensure safety. Egress alarms are not universally required, and excluding non-clinical or clerical staff is incorrect.