When use of restraints is prescribed for a client by a health care provider, which of these actions must the nurse take?
a. Insert a urinary catheter while the client is restrained.
b. Administer psychotropic drugs as ordered.
c. Assign a nursing assistant to sit with the client to gain cooperation.
d. Document client assessment and position changes.
D
Any device used to restrict movement is called a restraint. Documentation for a client in restraints must include data that demonstrates that the client has been toileted, received food and water, and position changes.
You might also like to view...
The process of understanding and applying researched clinical evidence to nursing practice requires the nurse to become information literate. Which of the following actions by the nurse best describes the use of information literacy?
a. Identifies a specific clinical problem, accesses appropriate resources, and assesses the relevancy of use of information for that particular patient's problem. b. Identifies a particular patient problem and immediately notifies physician and family for treatment. c. Identifies the lack of research skills and consults librarian for workshop on con-ducting research studies. d. Identifies lack of research skills and consults a scientific researcher to teach basic computer information.
Which treatment setting would necessitate the most restrictive care environment?
a. Partial hospitalization program b. Geropsychiatric unit c. Forensic hospital d. Group home
The nurse is preparing a patient with a suspected latex allergy for the radioallergosorbent test (RAST). Which of the precautionary steps is most important for the nurse to follow?
A) The test should be performed during bronchospasm. B) Scratch tests are performed after the RAST. C) Prick tests are performed after the RAST. D) Emergency equipment should be available.
A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? Select all that apply
A) A respiratory rate of 60 to 80 breaths per minute B) A breathing pattern that is often shallow, diaphragmatic, and irregular C) Periodic episodes of apnea D) The neonate's lung sounds may sound moist during early auscultation