295 Course Point flashcards (With complete solution)

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? correct answers The alternative measures attempted before applying the restraints 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? correct answers Use a safety monitoring device. The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform? correct answers Perform a circulation check and offer toileting and hydration. 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. correct answers 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 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? correct answers Assess the client's need for fluids and toileting every 2 hours. 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? correct answers extremity restraint After assisting a bed bound client with oral care, what action does the nurse take? correct answers Assist the client to a comfortable position in the bed. A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply. correct answers Toothbrush, Emesis basin, Disposable gloves, Toothpaste, Towel The nurse is assisting a hospitalized client with oral care. How will the nurse position the client? correct answers Sitting at the edge of the bed The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority? correct answers Decreasing the incidence of hospital-acquired pneumonia The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate? correct answers "Let me assess the patches. They may indicate the development of a fungal infection."