Quizzes for Clincal

The nurse considers applying restraints to an agitated client. Which actions does the nurse take?

"Dim the lights and speak softly about something the client enjoys." Rationale:The nurse attempts multiple techniques before restraining a person, even when the person is agitated. Among those techniques is providing a calming environment and distraction. The nurse can assess the client for injuries anytime he or she is agitated, but this is not immediately relevant. The client must at least be able to reach the call bell to request assistance and water, if allowed. Family members are not always helpful for someone with agitation, and a family member may find it difficult to accept that level of responsibility.

The nurse is caring for a 2-year-old child for whom elbow restraints have been prescribed. The nurse should remove the restraints and assess the child every how many hour(s)? _______

1 Rationale: Children under 9 years of age should have elbow restraints removed at least once every hour to make sure the restraints are not too tight and are not impeding circulation.

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?

Discontinue the infusion and record the volume left in the blood bag. Rationale:Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature.

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

Every 48 to 72 hours Rationale:In a non-infected wound, the negative pressure dressing should be changed every 48 to 72 hours. The negative pressure wound therapy should not be disturbed or interrupted more often than that unless the wound is infected. Infected wounds may require dressing changes every 12 to 24 hours.

A nurse is caring for a client who is wearing a waist restraint. Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted?

Insert the fist between the restraint and the client. Rationale:The nurse should insert one fist between the restraint and the client to ensure that the client's breathing is not constricted. Tying the restraint to the bed frame instead of the side rail and padding bony prominences are measures that help prevent injury, but they do not help prevent impaired breathing. Keeping a call bell within easy reach of the client would not help prevent impaired breathing.

The nurse is teaching a client the reasons for use of negative pressure wound therapy (NPWT). What should the nurse include in the teaching? Select all that apply

It promotes wound healing and wound closure. It provides a moist wound healing environment. It stimulates cell growth and growth of new blood vessels. It results in a reduction of bacteria in the wound.

Which finding best indicates to the nurse that the client has a therapeutic outcome from a blood transfusion?

The client has a steady gait while ambulating to void. Rationale:The expected outcome is best indicated by evidence of a stabilized cardiac output and fluid balance. This is observed through a lack of dizziness and steady gait and increased urine output. An increased blood pressure is a positive indicator; however, a blood pressure of 90/48 mm Hg is lower than desired. The client's positive color can indicate improved peripheral perfusion, or the client may be flushing as an effect of the transfusion. The absence of adverse effects, though desired, is not the best indicator of a therapeutic outcome.

The charge nurse is observing the new graduate nurse perform the dressing change for a client with negative pressure wound therapy. Which action by the graduate nurse will require the charge nurse to intervene?

The graduate nurse tightly stretches the transparent adhesive dressing and applies it to the wound. Rationale:The charge nurse would need to intervene when the graduate nurse tightly stretches the transparent adhesive dressing, because tight stretching of transparent adhesive drape during application may cause periwound damage. All other actions by the graduate nurse are correct.

The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse?

Use a safety monitoring device. Rationale:A bed exit safety monitoring device can allow the client to feel independent, while alerting nursing staff if the client needs assistance. Restraining the client takes away independence and can increase agitation and confusion. Asking a family member to sit with the client may help calm the client, but inappropriately transfers the nurse's responsibility to the family member. Checking on the client every 30 minutes is insufficient, because the client could fall and sustain injury during the unobserved intervals.

The nurse is accessing the implanted port of a client's central venous access device (CVAD) to administer medications. After holding the port stable, the nurse should insert the needle into which location?

center of the port Rationale:The nurse should visualize the center of the port and insert the needle through the skin into the port septum, located in the center of the port, until the needle hits the back of the port. To function properly, the needle must be in the middle of the port and inserted to the back wall of the port.

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client?

"Consult with your health care provider about beginning an exercise program." Rationale:The nurse should advise the client to consult with the health care provider to create a plan for an exercise program. Regular exercise, including cardiovascular exercise, helps maintain strength and flexibility and can help slow bone loss, all of which aid in fall prevention. However, the type of exercise and equipment should be determined by the health care provider or another qualified health care professional, not by the nurse.

A nurse is educating a client on the use of continuous oxygen. The nurse asks the client, "What is the advantage of using an oxygen mask versus a nasal cannula?" The nurse confirms that the education has been effective if the client states:

"I will have a greater concentration of oxygen delivered." Rationale:The greatest advantage of using an oxygen mask is the ability to deliver a more concentrated form of oxygen for clients who are not getting optimal results from a nasal cannula. With both systems, the air can be humidified prior to delivery. There is a greater chance of skin breakdown with the mask. The use of the mask does not damage nasal passages less than a nasal cannula.

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots.

The nurse must apply a mummy restraint to a small child. Place the steps in the correct order. Use all options.

1)Secure a prescription from the health care provider. 2)Explain the reason for use to the client and family. 3)Open the blanket or sheet and place the child on the blanket. 4)Position the child's right arm alongside the body and pull the right side of the blanket tightly over the child's right shoulder and chest. 5)Secure the blanket under the right side of the child's body. 6)Fold the lower part of the blanket up and pull over the child's body.

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform?

Perform a circulation check and offer toileting and hydration. Rationale:Restraints must be removed at least every 2 hours to facilitate circulation and allow the client to go to the bathroom and get fluids. Restraints are not used on an as needed basis but are used for a 24-hour period with breaks only for basic needs, like toileting. Even if the client suddenly seems calm, removal of the restraints is not permitted. Once this is done, a new prescription must be obtained and there are legal issues to consider. Bargaining with the client for restraint removal is not an acceptable nursing action. Restraint use is a safety measure, not a punishment.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Stop the transfusion and infuse normal saline using a new administration set. Rationale:A client who reports difficulty breathing during a blood transfusion may be having a transfusion reaction. The first action is to stop the transfusion and infuse normal saline using a new administration set. Changing the administration set prevents the client form receiving more of the blood that is causing the reaction. After stopping the transfusion and infusing normal saline using a new administration set, the nurse should check the client's vital signs and notify the health care provider of the reaction.

A toddler is to undergo a procedure for which the child needs to be restrained with a mummy restraint. The procedure is expected to take about 10 minutes. Which approach might the nurse suggest as an alternative to using a mummy restraint?

Therapeutic holding Rationale:An alternative approach for temporary restraint is therapeutic holding, which makes use of a secure, comfortable, temporary holding position that provides close physical contact with the parent or caregiver for 30 minutes or less. A vest or mitt restraint would not be an alternative to a mummy restraint. Straddling the child would be inappropriate.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

extremity restraint Rationale:The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.

A nurse is administering blood products to a client via an implanted port central venous access device (CVAD). What technique should the nurse use to locate the site of the port?

palpation Rationale:The nurse should put on clean gloves and palpate the location of the port. Because the port is implanted, observation alone should not locate the site. Percussion and auscultation would not be effective, because there are no associated sounds that should enable the nurse to locate the port.

The nurse is caring for an older adult for whom the health care provider has prescribed an elbow restraint. The elbow restraint should not impede circulation. Which pulse will the nurse assess to decide if circulation is compromised?

radial Rationale:The nurse should determine if circulation is compromised by assessing the radial pulse and the circulation to the fingers and hand. Assessing the apical, carotid, and jugular pulses will not help the nurse decide if the elbow restraint is compromising circulation.

The nurse is caring for an infant for whom the health care provider has prescribed a mummy restraint. The infant's parent asks the nurse what will be used to implement the mummy restraint on the infant. What is the best response by the nurse?

sheet or blanket Rationale:A small blanket or sheet is applied and folded to construct the mummy restraint. A vest restraint is made for adult clients. Towels are too small to be able to fold in the prescribed manner around the child. There are no manufactured mummy restraints.

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. A family member asks if the client will continue to wear the waist restraint. What is the best response by the nurse?

"The health care provider will see the client and assess whether the restraint prescription should be renewed." Rationale:After restraints have been worn for 24 hours, the health care provider who is responsible for the care of the client must see and assess the client before writing a new prescription for the use of restraint or seclusion for the management of violent or self-destructive behavior. The health care provider will indicate that the client should remain in restraints if violent or self-destructive behavior continues. The client must be taken out of restraints before discharge, but the nurse would not know whether the health care provider would continue to renew the prescription for restraints for each 24-hour period until the client's discharge. If tests were needed to determine why the client is violent, the health care provider would have prescribed them before this time.

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear." Rationale:All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up.

As prescribed by the health care provider, the nurse has set up an oxygen mask with a reservoir to deliver oxygen to a client with pneumonia. What would the nurse do, prior to putting the mask on the client?

Allow the reservoir bag to fill up with oxygen. Rationale:After connecting the face mask to the oxygen source, the nurse would adjust the flow rate to the prescribed amount and allow the bag to fill up with oxygen prior to placing the mask on the client. Because the reservoir bag supplies the oxygen administered to the client, it must be inflated with oxygen before application. The straps of the mask would be adjusted after placement on the client's face. Powder should not be used under the mask.

The nurse is providing care for several clients on a busy floor. The nurse receives a prescription to administer a transfusion of packed red blood cells for a client with decreased hemoglobin. Which action should the nurse take before entering the client's room to begin the transfusion?

Arrange for another nurse to monitor the nurse's other assigned clients. Rationale:Before administering a blood transfusion, the nurse should arrange for another nurse to monitor the nurse's other assigned clients for at least 15 minutes, because the nurse will need to remain with the client receiving the transfusion during this time to monitor for transfusion reaction. Verifying the client's name and date of birth with another nurse is important to avoid error and should happen at the bedside in the presence of the client medical record, client identification band, and the label of the blood product, not prior to entering the room. It is important for the nurse to obtain the client's vital signs immediately prior to starting the transfusion to obtain a baseline. Reviewing a prior assessment is not adequate. Changes in vital signs may indicate a transfusion reaction. The nurse will prime the blood administration set with normal saline solution only to prevent clumping of red blood cells and hemolysis.

The nurse is flushing the implanted port of a client's central venous access device (CVAD) and meets resistance. The nurse verifies that the clamp is open, pushes down on the needle, and, after attempting another flush, meets continued resistance. What should the nurse do next?

Ask the client to perform a Valsalva maneuver. Rationale:If resistance is met when flushing a client's implanted port, the nurse should first verify the clamp is open, push down on the needle, and attempt to flush again. If continued resistance is met, the nurse should ask the client to perform a Valsalva maneuver, change positions, or place the affected arm over the head. The access needle would not be changed until other remedies have been attempted. Flushing the port with heparin may prevent a port from clotting but will not resolve a clot. The health care provider should be notified after all remedies have been attempted; the health care provider may give a prescription for a clot-dissolving agent.

When accessing the implanted port of a central venous access device (CVAD), what action should the nurse take to ensure the port is patent?

Aspirate a few milliliters of blood into the extension tubing to check for blood return. Rationale:The nurse should check the patency of the implanted port of the CVAD by pulling back on the syringe plunger to aspirate for blood return. Positive blood return indicates that the port is patent. The nurse should aspirate only a few milliliters of blood and should not allow blood to enter the syringe. Flushing the port with 3 to 5 mL of saline checks that the needle is placed correctly. Air should not be used to flush the port as this can cause air embolism.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial interventions is appropriate?

Assess for the need to urinate. Rationale:Client needs should be assessed before considering physical or pharmacologic restraint.

The nurse in a critical care unit is caring for a child who is restrained with elbow restraints during a procedure. Which intervention should take priority?

Assess the circulation to the client's fingers and hands. Rationale:In this situation, assessing the circulation to the client's fingers and hands should be the priority intervention, because elbow restraints can impair circulation if applied too tightly. Keeping a call bell within easy reach would be a lower priority intervention, because the client is undergoing a procedure and is already in the company of the provider or other health care professionals. Assessing respirations to help prevent asphyxiation would be a priority intervention if the client were prescribed a waist restraint, not an elbow restraint. Encouraging the client to wear low-heeled, rubber-soled shoes would be a pertinent intervention for a client at high risk for falls.

The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate?

Assess the client's need for fluids and toileting every 2 hours. Rationale:Assessing fluids and toileting every 2 hours is necessary to maintain skin integrity and fluid balance. According to the UAP Nurse Practice Act, the duties of a UAP do not include performing assessments. The nurse should assist with the client's ADLs but allow the client the independence of performing as many as possible for oneself. The restraints should be secured to a non-movable part of the bed frame, and, thus, not to the side rail.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs. Rationale:First the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

The nurse is flushing the implanted port of a client's central venous access device (CVAD) and meets resistance. What should the nurse do next?

Check that the clamp is open, gently push down on needle, and attempt to flush again. Rationale:The nurse should first check the clamp to ensure that it is open, and then gently push down on the needle and attempt to flush again. If this does not work, the nurse could ask the client to perform a Valsalva maneuver, change the position, or place the affected arm over the head. The nurse could also lower or raise the head of the bed. If the port still does not flush, the needle should be removed and a new needle inserted. If the port does not flush this time, the health care provider should be notified.

After accessing the implanted port of a client's central venous access device (CVAD), what action does the nurse take to prevent air embolism?

Clamp the extension tubing Rationale:The nurse removes the syringe and clamps the extension tubing to prevent air from entering the CVAD, which may cause an air embolism. The tubing is flushed with normal saline prior to this step. Flushing the line with heparin helps to prevent clotting and ensures patency of the line. A heparin flush is not used if an IV fluid infusion is running; however, starting the infusion will not prevent an air embolism.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home. The nurse should recommend that the client's family ensure that walking paths and floors in the home are free of clutter, which is an environmental hazard that increases the risk of falls in the home. Changing routines, taking walks outside, and using the stairs will not reduce the risk of falling in the home.

In which client would negative pressure wound therapy be contraindicated?

Client with a moderately bleeding wound Rationale:Negative pressure wound therapy (NPWT) is contraindicated in the presence of: clotting disorders and acute mild to moderate bleeding in the wound region after injury/debridement; bleeding or risk of bleeding; wounds with exposed blood vessels, organs, or nerves; untreated osteomyelitis; wounds with a necrotic wound bed; non-enteric and unexplored fistulas; anastomotic sites; surgical suction; pleural, mediastinal or chest tubing drainage; and malignancy in wound tissue. NPWT is recommended for slowly healing wounds, wounds with heavy drainage, and wounds that are failing to heal.

The nurse is assigned a client for whom an elbow restraint is prescribed. Which general principles of correct placement of the elbow restraint will the nurse follow? Select all that apply.

Confirm the restraint does not extend below the wrist or place pressure on the axilla. Ensure the restraint is the correct size for the client. Pad bony prominences. Rationale:The nurse will need to choose the correct size of restraint, pad any bony prominences that may be affected by the restraint, and ensure that the restraint does not extend below the wrist or place pressure on the axilla. The restraint should be wrapped snugly but not tightly; wrapping it tightly can restrict circulation. The nurse should make sure that two fingers, not a fist, can easily fit under the restraint.

The health care provider prescribes oxygen to be administered to a client via a mask with an oxygen flow rate of 10 liters per minute. To accommodate meals, what would the nurse do?

Deliver oxygen via nasal cannula during meals, replacing the mask after the client eats. Rationale:The client cannot eat with an oxygen mask on; therefore, the nurse should secure a prescription for oxygen administration via a nasal cannula during meals. Since the flow rate is not as great with a nasal cannula, the mask should be replaced as soon as the client is finished eating. It would not be appropriate to remove the oxygen during meals without applying the nasal cannula, because the client would become hypoxic while eating. Replacing the mask as soon as the client is finished eating is not sufficient, because the client would become hypoxic before finishing eating. Loosening the mask while the client is eating would allow too much oxygen to escape during the meal and risks hypoxia. There is no need to change the client's diet.

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply.

Ensure the parent engages in regular exercise., Increase the parent's social interaction., Provide frequent reorientation. Rationale:The nurse should instruct the adult child to provide frequent reminders of person, place, and time to help keep the client oriented in the environment and decreases the chance that the client will wander. The nurse should also instruct the adult child to ensure the parent engages in regular exercise and to work to increase the parent's social interaction, both of which help clients with dementia channel stress more appropriately. Taking naps frequently does not help to reorient the client with dementia or to channel energies. Changing the parent's routine frequently can disorient a client with dementia and increase the chance that the client will wander.

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency?

Every 1 to 2 hours Rationale:The nurse would plan on increasing the frequency of client observation and surveillance, conducting client/nursing rounds every 1 to 2 hours. These rounds would include assessing for pain, assisting with toileting, providing client comfort, ensuring that personal items are within reach, and meeting client needs. Client care rounds/nursing rounds improve identification of unmet needs, which can decrease behaviors that increase risk for the use of restraints.

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include? Select all that apply.

Falls, Contractures, Delirium, Pressure injuries Rationale:Restraint-free care is the standard of practice and an indicator of quality care in all health care settings. Physical restraints do not prevent falls, and they increase the possibility of serious injury due to a fall. Restraint use in older adults is associated with falls and injurious falls, pressure injuries, and other adverse outcomes. Additional negative outcomes of restraint use include skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration and respiratory difficulties, and even death.

The nurse is caring for a client who has an implanted port central venous access device (CVAD) and needs to have an intravenous (IV) solution infused. The nurse has appropriately prepared the solution, the infusion set, and the port site. Just before inserting the access needle, the nurse notes that it is bent at an angle. Which action is correct?

Insert the needle through the skin into the center of the infusion port and begin the infusion. Rationale:Implanted port CVADs are accessed with a specially-designed, angled needle; the nurse should not attempt to straighten it or replace it.

The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply.

Name on the client's identification band, Number on the client's identification band Rationale:Two nurses must compare and validate the following information with the medical record, client identification band, and the blood product label: medical prescription for transfusion of blood product, informed consent, client identification number, client name, blood group and type, and expiration date. The client's vital signs and room number and the patency of the venous access device are not required to be validated by two nurses.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?

Oxygen hood Rationale:An oxygen hood is a delivery device for infants that can deliver oxygen concentrations up to 80% to 90%. None of the other devices listed can deliver oxygen at the concentration needed.

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. What should the nurse do immediately before applying the waist restraint?

Pad bony prominences. Rationale:Immediately before applying the waist restraint, the nurse should assess and pad bony prominences that may be affected by the waist restraint. The nurse should use a quick-release knot after applying the restraint. The restraint should be not tied tightly, but snugly. Securing the restraint too tightly could impair the client's breathing. The nurse should remove PPE after applying the restraint.

A nurse is preparing to access the implanted port of a client's central venous access device (CVAD). The nurse asks the client to turn the head away from the access site, but the client is unable to do so. What is the next action by the nurse?

Place a mask on the client. Rationale:Turning the head away from the access site helps to deter the spread of microorganisms. If a client is unable to turn the head away from the site, the nurse should place a mask on the client to help deter the spread of microorganisms. Masks may also be necessary based on facility policy. Asking the client to hold the breath, look away, or avoid coughing would not be effective in preventing the spread of microorganisms.

The nurse is applying an oxygen mask prescribed for a client with bronchial pneumonia. What would the nurse do to prevent skin breakdown in the area where the mask is placed?

Place gauze pads under the elastic strap at pressure points. Rationale:If skin irritation or redness is noted, the nurse would use gauze pads under the elastic strap at pressure points to reduce pressure and protect the skin. The mask should fit snugly around the mouth and nose, so cotton balls and powder would not be placed beneath the edges of the mask. The straps should be adjusted to fit snugly, but comfortably, on the face.

The nurse is unable to flush the implanted port of a client's central venous access device (CVAD), despite repeated efforts at repositioning the client. Which action by the nurse is most appropriate?

Reaccess the port with a new needle, according to facility policy. Rationale:If resistance is met when flushing the client's implanted port and the nurse has attempted all remedies including changing client position, the nurse should reaccess the port with a new needle and attempt to flush again, according to facility policy. After the port has been reaccessed and the nurse is still unable to flush the port, the nurse should contact the health care provider for a further prescription. Placing the client's arm below the level of the heart will not remedy the problem. Increasing pressure or "forcing" the flush may result in damage to the port and should not be attempted.

Which recommendations should be included in a teaching plan for preventing falls in the home? Select all that apply.

Remove clutter from walkways. Use a night light. Keep electrical and telephone cords against the wall and out of walkways. Avoid climbing on a chair or table to reach items that are too high to reach. A teaching plan for fall prevention in the home should include the recommendations: avoid climbing on a chair or table to reach items that are too high to reach; use a night light; remove clutter from walkways; and keep electrical and telephone cords against the wall and out of walkways. Considering the use of an electronic personal alarm would not help prevent a fall, but it may be used to help alert others to the fact that one has fallen.

The nurse is caring for a middle-aged adult who has been prescribed elbow restraints. The nurse observes that when the restraints are removed, the client cries and reports pain in the elbow. What is the best action by the nurse?

Remove restraints more frequently and perform range of motion (ROM). Rationale:If a client cries or reports discomfort or pain when elbow restraints are removed, the nurse should remove the restraints more frequently and perform active or passive ROM. Eliminating the restraints would alleviate the client's pain only if the reason for which the restraints were prescribed has resolved. The nurse could reassess and consider another type of restraints, but it is better to continue with the type of restraints prescribed by the health care provider. A padded dressing will not alleviate the client's pain, because the restraints are already padded.

The nurse is caring for a client receiving oxygen at a rate of 8 liters per minute via face mask. While monitoring the client for skin irritation, what is the best action by the nurse?

Remove the mask and dry the skin every 2 to 3 hours. Rationale:The nurse would remove the face mask, dry the skin under the mask, and assess for skin breakdown every 2 to 3 hours. Skin integrity can be compromised due to mask pressure and moisture under the mask. Changing the oxygen delivery system would not be an appropriate nursing action. Lifting the mask to dry the skin every 4 to 5 hours would not be often enough to prevent skin compromise. Continuing to monitor is necessary, but it is not the best action, because simply monitoring does not prevent skin breakdown or eliminate the moisture from the skin.

A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types?

The client continually tries to move from head of the bed toward the foot of the bed. Rationale:Research suggests that waist restraints pose the same risks for asphyxial death as vest restraints. When the client is very mobile in the bed or chair, the risk for asphyxiation increases. The nurse should pad skin and bony prominences that will be covered by the restraint to reduce friction and pressure to skin and underlying tissue. Restraints ground a client's center of gravity, thus helping to prevent injuries and falls such as rolling off a stretcher or falling out of bed. Because the nurse should be following the removal schedule (every 2 hours), the client is at less risk for incontinence and dehydration because these needs are being met every 2 hours.

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client?

every 60 minutes Rationale:If a client who is at high risk for falls has no access to an activated bed or chair alarm, a nurse should observe the client every 60 minutes. Unless the client is on one-to-one observation, every 30 minutes is too frequent. Once a shift, or at 2- or 4-hour intervals, is too infrequent.

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home? Select all that apply.

extension cords clutter polypharmacy Rationale:In the home of an older adult, the use of extension cords and clutter in the walkways are environmental hazards that increase the risk of falls in the home. Polypharmacy is common risk in the home of an older adult client. Placing objects in familiar places helps to decrease the risk in the home of an older adult. Using ambulation devices helps to decrease the risk of falls in the home of the older adult.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

the alternative measures attempted before applying the restraints Rationale:Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.

After applying a restraint to a client, the nurse is required to stay with the client while it in use. Which type of restraint has the nurse applied?

mummy restraint Rationale:A mummy restraint restricts all movement, and thus the nurse should stay with the client while it is in place. The other types of restraint do not restrict the client's movements as completely and thus require checks at specified intervals, but not the constant presence of the nurse.

The nurse is caring for a hysterical child who requires assessment of a dog bite near the eye. The parent is in emotional state that is not appropriate for helping to immobilize the child. The nurse should implement which restraints to best enable the health care provider to examine the client's injury?

mummy restraint Rationale:The mummy restraint is appropriate during an examination or while providing care for the head or neck, because it provides short-term restraint designed to control all movement. The vest restraint, extremity restraint, and elbow restraint are not appropriate in this situation.

The nurse is preparing to administer a waist restraint to a client in a wheelchair. Which method of securing the restraint is appropriate?

tying the restraint behind the chair Rationale:The nurse should run the restraint under the arm rests and tie it behind the chair. Tying the restraint out of the client's reach promotes security. Tying the restraint to the side rail or in the front of the chair would allow the client to untie the restraint. Tying the restraint under the chair would not provide the nurse with swift access to the quick-release knot.

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene?

waiting outside of the closed bathroom door while the client uses the toilet Rationale:To prevent falls for a client who is at high risk for falls, the nurse should not wait outside the closed bathroom door but should remain with the client in the bathroom and assist the client in toileting. The other actions are appropriate measures for a client who is at high risk for falls and would not require the charge nurse to intervene.