Chapter 4 - Safety: NCLEX-Style Practice Questions

Chapter 4 - Safety: NCLEX-Style Practice Questions

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NCLEX - Safety: Restraints

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Quiz: Fall Prevention

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14 terms jess The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

• The client is wearing the oxygen around the neck.
• The skin is a bluish-color.
• The IV is not infusing at the correct rate.
• There is spilled water on the floor.
• The client's television is turned off.

A, B, C, D

All of these items are cause for concern.

• SpO2 may be decreased if O2 is not worn properly.
• tubing around the neck and spilled water are safety issues.
• Cyanotic skin is a result of poor perfusion or coldness, and could be related to

the improper donning of the O2.The nurse typically delegates a situational assessment to the unlicensed assistive personnel (UAP) for the home care client with heart failure. Which finding cuases the nurse to perform this assessment rather than delegate it?

• The UAP has a large work load and doe not feel able to

do the task.

• The regulations of the Nurse Practice Act state this

cannot be done.

• The manager wants the UAP to go through additional

training on documentation.

• The client went to the emergency department to be

evaluated after a fall.

• The nurse performs the assessment because there has been a change in the

client's condition. Any acute change warrants an assessment by the RN.

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?

• It is important to us that you remain free from injury.
• Do not get up without assistance for any reason.
• You will mostly stay in bed while you are hospitalized.
• Use the call bell for any needs and wear nonslip

footwear.

• All 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.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 30min
• every 2 hours
• every 60min
• every 4 hours
• Patients at risk for falls should be assessed hourly.

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

• Use the stairs in the new home
• Change the older adult's routine
• Clear cutter in the walkways of the new home.
• Take walks outside.
• 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 risks of falls in the home.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 that the parent's routine changes frequently.
• Ensure the parent engages in regular interaction.
• Increase the parent's social interaction.
• Provide frequent reorientation.
• Ensure the parent to take naps frequently.

B, C, D.

Both exercise and social interaction help clients with dementia channel stress more appropriately.Reminders of person, place and time help keep the client oriented in the environment and decreases the chance of wandering.The nurse considers applying restraints to an agitated patient. Which actions does the nurse take?

• Call a family member to come and sit with the client.
• Assess the client for existing injuries to the wrists and

hands.

• Dim the lights and speak softly about something the

client enjoys.

• Ensure the client cannot reach any objects in the room.
• RESTRAINTS ARE A LAST RESORT. Try multiple techniques BEFORE applying

restraints. Among these techniques is providing a calming environment and distraction.

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

• Assess for the need to urinate.
• Contact the health care provider for a prescription to

apply a waist restraint.

• Raise the side rails.
• Administer a prescribed dose of lorazepam.
• Client needs should be assessed before considering physical or

pharmacological restraint. RESTRAINTS ARE A LAST RESORT.The nurse is preparing to aply prescribed extremity restraints to a client's ankles. What is the procedure of steps the nurse should perform?

• Explain rationale for use to the client and family.
• Pad bony prominences.
• Wrap restraint around the client's ankle and secure it with hook-and-loop

fastener straps.

• Ensure two fingers fit betwee the restraint and the client's skin.
• Position limbs in the normal anatomical position.
• Secure restraints to the bed frame with quick release knots.

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.

• A verbal prescription for the restraints, renewed every

48 hours.

• A detailed description of the restraint application

process.

• The type of PPE used by the nurse during restraint

application.

• Reasonable measures to avoid the use of restraints must be attempted before

implementation; these measures MUST be documented.The nurse 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?

• Mummy restraint.
• Elbow restraint.
• Extremity restraint.
• Waist restraint.
• Extremity restraints are appropriate during an accidental removal of

therapeutic devices because they provide short-term restraint designed to control all movement.A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types?

• the client has frequent and large episodes of stool and

urinary incontinence.

• the client continually tries to move from head of the

bed toward the foot of the bed.

• the client has preexisting pressure injuries and skin

breakdown on bony prominences.

• the client has a high risk of injuries and falls related to

confusion and medications.

• Research suggests that waist restraints pose the same risks for asphyxial death

as vest restratints. When the patient is very mobile in the bed or chair, this risk increases.

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?

• keep a call bell within easy reach of the client.
• insert the fist between the restraint and the client.
• tie the restraint to the bedframe, not the side rail.
• pad the client's bony prominences.
• The nurse should insert one fist (thumb to sternum) between the restraint and

the client to ensure that the client's breathing is not constricted. Respiratory status should be assessed every 15 minutes for the first hour.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 under the chair.
• tying the restraint behind the chair.
• tying the restraint in the front of the chair.
• tying the restraint to the side rail of the chair.
• 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.The nurse is caring for a 2yo child for whom elbow restraints have been prescribed. The nurse should remove the restraints and assess the child every how many hour(s)?Every 1 Hour.Children under 9 years of age should have elbow restraints removed at least once every hour to make sure restraints are not too tight and are not impeding circulation. ROM exercises should also be performed.The nurse in a critical care unit is caring for a child who is restrainted with elbow restraints during a procedure.Which intervention should take priority?

• Assess the circulation to the client's fingers and hands.
• Keep a call bell within easy reach of the patient.
• Assess respirations to help prevent asphyxiation.
• Encourage the client to wear low-heeled, rubber-soled

shoes.

• In this situation, assessing circulation to the client's fingers and hands should be

the priority intervention because elbow restraints can impair circulation if applied too tightly.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?

• Apply a padded dressing under the restraints.
• Reassess the client and consider a different type of

restraint.

• Eliminate the use of restraints.
• Remove restraints more frequently and perform range

of motion (ROM).

• If a client cries or reports discomfort or pain when the restraints are removed,

the nurse should remove them more frequently and perform active or passive ROM.