Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?
A. Monitor the client's range of motion every 60 min.
B. Offer the client a nutritious snack every 4 hr.
C. Plan to remove the restraints as soon as the client is calm
Physical restraints should be used as a last resort and for the shortest duration possible to ensure client safety. The nurse should assess the client frequently and remove the restraints when they are no longer needed.
D. Ensure that the provider has signed a prescription for restraints within 48 hr.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is C. Plan to remove the restraints as soon as the client is calm. Physical restraints should be used as a last resort and for the shortest duration possible to ensure
client safety. The nurse should assess the client frequently and remove the restraints when they are no longer needed.
Similar Questions
A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?
A. Assists the client to the bathroom every 2 hr
B. Raises all four side-rails on the client's bed
Raising all four side-rails on the client's bed is considered a restraint and can increase the risk of injury if the client tries to climb over them. The nurse should intervene and instruct the AP to lower one or two side-rails and use other fall prevention measures, such as bed alarms, nonskid footwear, and frequent checks.
C. Locks the wheels on the client's bed
D. Clears furniture from the path leading to the bathroom
Full Explanation
The correct answer is B. Raising all four side-rails on the client's bed is considered a restraint and can increase the risk of injury if the client tries to climb over them. The nurse should intervene and instruct the AP to lower one or two side-rails and use other fall prevention measures, such as bed alarms, nonskid footwear, and frequent checks.
A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?
A. Daytime drowsiness
B. Hypoglycemia
C. Palpitations
D. Muscle pain
Muscle pain is a sign of rhabdomyolysis, a rare but serious condition that can occur with statin use and can lead to kidney failure. The nurse should instruct the client to report any muscle pain, weakness, or tenderness to the providerimmediately.
Full Explanation
The correct answer is D. Muscle pain is a sign of rhabdomyolysis, a rare but serious condition that can occur with statin use and can lead to kidney failure. The nurse should instruct the client to report any muscle pain, weakness, or tenderness to the provider immediately.
A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?
A. The room numbers of the clients
B. The diagnoses of the clients
C. The names of the clients' nearest relatives
D. The telephone numbers of the clients
The telephone numbers of the clients are unique identifiers that can be used to verify their identities before administering medications. The room numbers, diagnoses, and names of relatives are not reliable identifiers because they can change or be shared by other clients.
Full Explanation
The correct answer is D. The telephone numbers of the clients are unique identifiers that can be used to verify their identities before administering medications. The room numbers, diagnoses, and names of relatives are not reliable identifiers because they can change or be shared by other clients.