Nokea
The nurse is observing client care situations. Which of the following situations would require an order for physical restraints? Select all that apply.
- A. A long leg immobilizer is used for a client with a fractured tibia.
- B. A mummy restraint is used for an infant while the nurse obtains a blood specimen.
- C. Full padded side rails are placed in the raised position for a client who is experiencing a seizure.
- D. A belt restraint is used for a client with confusion who is on bed rest but continually attempts to get out of the bed.
- E. A soft ankle restraint is used to prevent bleeding at the femoral site for a client who had a cardiac catheterization and is drowsy.
Correct Answer: D,E
Rationale: Belt and ankle restraints require a provider's order due to their restrictive nature. Immobilizers, mummy restraints, and padded rails are typically used for specific purposes without restraint orders.
You may also like to solve these questions
The nurse is caring for a 5-year-old client with sickle cell disease who is experiencing an episode of acute pain. The client has shortness of breath, nausea with vomiting, and severe generalized body and joint pain. Which of the following findings requires immediate intervention?
- A. enlarged spleen on palpation
- B. hemoglobin level of 9.0 g/dL (90 g/L)
- C. bilateral swelling of the hands and feet
- D. pain rated as 8 on the Wong-Baker FACES Scale
Correct Answer: A
Rationale: An enlarged spleen may indicate splenic sequestration, a life-threatening complication requiring immediate intervention.
The nurse is caring for a 2-year-old client who has iron deficiency anemia. The nurse should recognize that this condition is most likely the result of
- A. impaired iron transfer from the mother
- B. excessive intake of meat products
- C. excessive intake of cow's milk
- D. gastrointestinal blood loss
Correct Answer: C
Rationale: Excessive cow's milk intake in toddlers can lead to iron deficiency anemia due to low iron content and potential for gastrointestinal irritation.
A hearing-impaired client is becoming withdrawn and depressed. He reports that even with a hearing aid, he is having increased difficulty hearing. Which suggestion is least likely to be helpful?
- A. Get a hearing guide dog.
- B. Join a social club.
- C. Get a telephone TDD.
- D. Get a closed-caption TV.
Correct Answer: A
Rationale: A hearing guide dog is less helpful for communication compared to social engagement, TDD, or closed-caption TV, which directly address hearing loss.
Triazolam (Halcion) 0.25 mg is ordered for a client at bedtime. When the nurse goes to give the medication, the client asks the nurse to leave it at the bedside because she wants to finish reading a book. What is the best action for the nurse to take?
- A. Leave the medication at the bedside as requested
- B. Return in one hour and offer the medication again
- C. Tell the client to call when she is ready for the medication
- D. Explain to the client that this is the time medications are given and she should take it now
Correct Answer: B
Rationale: Returning in an hour ensures medication administration while respecting the client's request, adhering to safety protocols. Leaving medication or delaying indefinitely risks errors.
The nurse finds a person unresponsive on the floor. What is the initial nursing action?
- A. Start chest compressions
- B. Assess respirations and pulse
- C. Place on a hard surface
- D. Start mouth-to-mouth breathing
Correct Answer: B
Rationale: Assessing respirations and pulse determines if CPR is needed, per ACLS guidelines. Compressions, positioning, or breathing are premature without confirming unresponsiveness and absence of pulse/breathing.