Module 6 Safety and Infection Control questions with correct answers

After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. correct answer B The restraints are being released every 2 hours. C A safety knot has been used to secure the restraints. E The call light has been placed within reach of the client. Rationale: Restraints should never be applied tightly, because this could impair circulation. They should be tied to the bed frame (not the siderail) with the use of a safety knot. The client could sustain injury if the siderail were lowered with a restraint attached to it. A safety knot is used because it can easily be released in an emergency. Restraints must be released every 2 hours to facilitate inspection of the skin, help ensure good circulation, and permit movement of the joint through its range of motion. The call light must always be within reach of the client in case he or she needs assistance. A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. correct answer A A victim with respiratory distress C A victim with partial amputation of the foot Rationale: One rating system commonly used in the ED consists of three tiers — emergent, urgent, and nonurgent — with the categories sometimes identified with color coding or numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life-threatening injuries (here, the clients with respiratory distress [airway] and partial amputation of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation but have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a. yellow or priority 2) classification is given to clients whose injuries and complications are not life threatening (here, the client with the fractured humerus), provided that they are treated within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The nonurgent (a.k.a. green or priority 3) classification is given to clients with local injuries (here, the clients with the forehead laceration and bruises of the arms and legs) who do not have immediate complications and can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter.