Nokea
The nurse manager is providing an educational session to the nursing staff on the safe use of physical restraints. Which are examples of safety guidelines when using physical restraints? Select all that apply.
- A. Restraints should be secured with a quick-release tie.
- B. A primary health care provider's prescription is required.
- C. Restraints are secured to side rails so that they can be easily removed as necessary.
- D. Restraints are used when other measures have failed to prevent selfinjury or injury to others.
- E. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms.
- F. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them.
Correct Answer: A,B,D
Rationale: A physical restraint is a mechanical or physical device that is used to immobilize a client or extremity. It restricts the freedom of movement or normal access to a client's body. A primary health care provider's prescription is required for the use of restraints. Restraints should be secured with a quickrelease tie so that they can be easily removed in an emergency. Restraints are considered for use only when other measures have failed to prevent self-injury or injury to others. Restraints are secured to the bed frame, not the side rails, because the client may be injured if the side rail is lowered. Restraints, not a usual part of treatment plans, may be indicated by the person's condition or symptoms, and are not prescribed on a PRN basis.
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The nurse is planning care for a client with a diagnosis of acute glomerulonephritis. Which action should the nurse instruct the unlicensed assistive personnel (UAP) to implement in the care of the client?
- A. Ambulate the client frequently.
- B. Encourage a diet that is high in protein.
- C. Monitor the temperature every 2 hours.
- D. Remove the water pitcher from the bedside.
Correct Answer: D
Rationale: A client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction, as well as monitoring weight and intake and output. The client may be placed on bed rest or at least encouraged to rest because a direct correlation exists among proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.
The nurse is preparing to administer prescribed amiodarone intravenously. To provide a safe environment, the nurse should ensure that which specific safety consideration is in place for the client before administering the medication?
- A. Oxygen therapy
- B. Oxygen saturation monitor
- C. Continuous cardiac monitoring
- D. Noninvasive blood pressure cuff
Correct Answer: C
Rationale: Amiodarone is an antidysrhythmic medication that affects cardiac rhythm. Continuous cardiac monitoring is essential to detect any adverse effects such as arrhythmias, which can be life-threatening. This ensures a safe environment for the client during administration. Oxygen therapy and oxygen saturation monitoring are not specific requirements for amiodarone administration unless indicated by the client's condition. A noninvasive blood pressure cuff is useful but not the primary safety consideration compared to cardiac monitoring.
The nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?
- A. Note the child's physical symptoms.
- B. Prepare the child for hydrostatic reduction.
- C. Prepare the child and parents for the possibility of surgery.
- D. Report the passage of a normal brown stool to the primary health care provider.
Correct Answer: D
Rationale: Intussusception is the telescoping of one portion of the bowel into another portion. Passage of a normally formed brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the primary health care provider, who may choose to alter the diagnostic or therapeutic plan of care. Although the nurse would note the child's physical symptoms, based on the data in the question, option 4 is the appropriate action. Hydrostatic reduction and surgery may not be necessary.
The registered nurse (RN) planning the assignments for the day is leading a team composed of a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Based on licensure, which client is most appropriate to assign to the LPN?
- A. A client diagnosed with dementia
- B. A 1-day postoperative mastectomy client
- C. A client who requires some assistance with bathing
- D. A client who requires some assistance with ambulation
Correct Answer: B
Rationale: Assignment of tasks must be implemented based on the job description of the LPN and UAP, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The UAP has the skills to care for a client requiring noninvasive care such as a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.
Which action demonstrates a situational leadership style by the nurse manager?
- A. The nurse manager delegates tasks to each team member.
- B. The nurse manager allows team members to work without supervision.
- C. The nurse manager invites team members to provide input about a unit problem.
- D. The nurse manager quickly delegates activities to team members during an emergency situation.
Correct Answer: D
Rationale: The situational leadership style uses a style depending on the situation and events. This type of leadership style is used in emergency situations when the nurse manager needs to quickly delegate activities to achieve a successful outcome for the situation. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. Participative leadership demonstrates an 'inbetween' style, neither authoritarian nor democratic. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. The autocratic style of leadership is task oriented and directive.