A nurse is caring for a client who has a prescription for wrist restraints

a nurse is caring for a client who has an incisional wound and a prescription for wound care. Saw palmetto D. Withhold food and drink until the restraints are removed from the client A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. Which of the following actions should the nurse take? O A. Documentation is extremely important if you have a patient in restraints. Keep 4 side rails up while the client is in bed c. A nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints Which of the following actions should the nurse take? a. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. A nurse is caring for a client who is pulling at his abdominal wound drains. A nurse is caring for a client who has a new prescription for citalopram. Request that the provider provide an as-needed prescription for restraints. 45. “I need to set my hot water heater to 140 degrees Fahrenheit. Which of the following actions should the nurse take? A. Client: A client is a person or persons with whom the nurse is engaged in a professional therapeutic relationship. Hospital Restraint/Seclusion Deaths: 42 CFR § 482. type of restraints for the child with a cleft palate repair are: A. Which action is most important for the nurse to implement when donning sterile gloves? Keep gloved hands above the elbows. A nurse is caring for a client who has restraints to each extremity. Permit 3 finger-widths to slide between the patient’s wrists and the restraints. You will need to pass the STNA test in order to work as a State Tested Nurse Aide in Ohio. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube 3. Have the client crutch walk in the room. application of wrist and ankle restraints b. Surgery with Kirschner wire implantation developing the nursing plan of care and modifying the plan as indicated by ongoing assessment and evaluation. Mummy restraints A client with diabetes mellitus has a prescription A. A nurse is caring for a client who has a prescription for escitalopram. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. A nurse is caring for a client who has a fractured hip and is postoperative open reduction and internal fixation. If your relative is your legal guardian, he or she has the right to look at all medical records about you. To which of the following parts of the bed should the nurse secure the restraints? 52. A) Check the site of the restraint every 30 minutes. Nurse is caring for a client who has a mutation of the BRCA2 gene, client states she 16. Remove the restraints every 3 hr, A 90-year-old client from a long-term care facility has been hospitalized for dehydration. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. A. The client is combative and confused, yells at the staff and became caught in the bed rails while trying to climb out of bed. Set up a time for individual meetings with the client. In accordance with requirements at 42 CFR § 482. Question 60 A nursing assistant begins caring for a client during a bed bath and notes he has a reddened, intact area on his coccyx. Which of the following interventions should the nurse include in the plan of care? Renew the prescription for the use of restrains within 24 hr Wrist restraints. Teaching new nurse about obtaining telephone prescription Sample Assignment. A nurse is caring for a client who requires airborne precautions. Pancreatitis. O Remove the restraints every 3 hr, Hospital Restraint/Seclusion Deaths: 42 CFR § 482. Which of the following actions should the nurse take first? a. Which of the following actions should the nurse take? A nurse is caring for a client who has diarrhea due to shigella. Comfort level. and stiffness and pain in the shoulders. Evaluate the client’s circulation once per shift after application A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. The client has a prescription for metoprolol C. Elements A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take to prevent the spread of infection? 4. A nurse is caring for a client who has influenza and isolation precautions in place. Obtain the patient’s informed consent to the use of restraint, or the consent of the patient’s surrogate when the patient lacks decision-making capacity. Training should take place before staff A nurse is caring for a client who has symptoms of chills. This guideline provides evidence-based recommendations for Registered Nurses (RNs) and Registered Practical Nurses (RPNs) related to the care of individuals who are at risk for behaviours that may result in harm to self/others and lead to the possible use of restraints (physical, chemical, environmental). Which concern should the nurse have for planning care in terms of the client’s beliefs? Blood transfusions are forbidden. A doctor or another provider must also be told restraints are being used. Benztropine (Cogentin) 2 mg p. Monitor the client at least once every hour d. restraints to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. 19. Common types of restraints include soft mitts and soft wrist or ankle restraints. Elimination needs. The nurse finds the following prn medications ordered for the client. Cola is acceptable to drink on the day of the test. The doctor or other provider must then sign a form to allow the continued use of restraints. Determining if the membranes have ruptured; 48. Pad the client’s wrists before applying the restraints b. A client who is a Jehovah’s Witness is admitted to the nursing unit. You must be able to demonstrate competency in the application of restraints, implementation of se-clusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. Patient restraints are medical devices used in medical and psychological settings to help ensure patient and staff safety. a nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. Which treatment should the nurse anticipate for the fractured foot? Application of a short inclusive spica cast. A client under the nursing assistant’s care suffers from chronic “foot drop”. Nurses used either wrist, ankle, or whole body restraints at various levels. You have the right to help plan the care for yourself. A soft restraint is a device that is placed on the wrist or ankle with Velcro. Wrist restraints D. A nurse is caring for a client who is agitated and threating to harm others. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Patients who are restrained need special care to make sure they: A nurse is caring for an older adult client who is disoriented and has a history of falls. Report the incident to the pharmacy. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take? 10. Remove the client restraints every 4 hours. Assign the client to a private room b. Nurse is caring for a client who has a mutation of the BRCA2 gene, client states she A nurse is caring for an older adult client who is disoriented and has a history of falls. John’s wort C. Client C, a 56-year-old client who has a prescription for ketorolac and who had shoulder surgery. Request a PRN prescription for restraints 19. never. IMPLEMENTATION is the third step of the nursing process and consists of delivering nursing care according to an established health care plan and as assigned by the RN or other person(s) authorized by law. 44. A nurse has a prescription to apply wrist restraints to maintain a client's safety. Mummy restraints 13. Which one should the nurse administer? a. Which of the following images indicates the proper method of cleaning a wound site? a nurse is caring for a client who reports a pain level of 5 on a scale of 0- 10. E. Stabilization with a plaster-of-Paris cast. A health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. Obtain a prescription to restrain the client PRN. B) Remove the wrist restraints to provide skin care every 2 hours. Check on the client hourly. A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Inquiry Office. avoidance of physical contact c. 13(g), Death Reporting Requirements, all patient deaths associated with restraint or seclusion (except 2-point soft wrist restraints that must be recorded in an internal hospital log or other system) in a hospital are required to be reported to the Centers for Medicare & Medicaid The American Health Care Association (AHCA), which represents the nursing home industry, tried to convince the CMS to soften the pharmacist requirements. STNA Practice Test. 32, as amended, and defined in subsection 1(37) of the Ontario Regulations 799/93 Care Agreement. Elimination needs D. nasal congestion. Which of the following precaution should the nurse take? A nurse is caring for a client who has a respiratory infection. This information is on the care plan and your assignment sheet. You also have the right to safe care and to be treated with respect when restraints are used. careful observation and supervision d. The nurse is caring for a client following removal of the thyroid. Wrist restraints. Which of the following actions should the nurse take? Pad the client's wrist before applying the restraints. Which is the best way for the nurse to assess blood pressure? A client has a soft wrist-safety device. The nurse is caring for a client who has been taking fluphenazine (Prolixin) for 2 days. ) Raise all side rails on the client's bed. Remove one restraint at a time. The nurse places the If restraints are needed for medical reasons, a doctor’s order is required. In an emergency, the nurse can decide to apply restraints before getting a doctor’s order. Peripheral pulses ABCS always first. To which of the following parts of the bed should the nurse secure the restraints? A nurse is caring for a client who is pulling at his abdominal wound drains. A soft mitt is a large glove that covers the hand. An elderly client who experiences nighttime confusion wanders from his room into the room of another client. A nurse is caring for a client in the evening after the client has had a below-the-knee amputation. Which of the following actions should the nurse take? Pads the client wrist before applying the restraints 10. Which of the following actions should the nurse take? Remove the restraints with each vital sign check. Unless otherwise indicated in the guideline, the discussion focus is on physical restraint. A client who is ordered to be discharged. A nurse precepting a newly licenced nurse who is caring for a client who is confused and has an IV infusion. fever. Which of the following assessments should the nurse perform first? a. 32, as amended, and defined in subsection 1(37) of the Ontario Regulations 799/93 A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. eliminate pain from the surgical site. The client states, “I can feel worms crawling through my vein. 51. What are restraints? A restraint is anything that prevents or limits a patient from being able to move their arms, legs or body freely. Pain assessmentpolicy 6. Instruct the client in the use of the call light. A nurse is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Pad the client’s wrist before applying the restraints. What should the nurse do when applying this type of restraint? Check the site of restraint every 30 mins The licensed nurse may also accept and implement orders for client care and treatment from Physician Assistants licensed under ORS 677, provided that the name of the supervising or agent physician is recorded with the order, in the narrative notes, or by a method specified by the health type of restraints for the child with a cleft palate repair are: A. Attach the restraints to the beds side rails c. The most effective way to decrease the spread of microorganisms is: A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is an. O Secure restraints with a square knot. Gastric ulcers. Ask the family to stay with the client. Client has been prescribed wrist restraints. The nurse should recognize that this medication can result in an adverse interaction when taken with which of the following over-the-counter supplements? A. Request a PRN restraints prescription for clients who are aggressive d. Tie the restraints to the side rail. The client has intravenous fluid infusing. At 11:00 PM, the charge nurse makes rounds on all of the clients in the unit. 17. no sweating. Reapply the elastic bandage every two 8. upper back. Which of the following actions should the nurse take? 10. Our STNA practice test features 79 questions that are similar to those on the actual test. After attempting to reorient the client, the client remains unable to demonstrate appropriate use of the call light. Fish oil B. An important facet of nursing care for G will be a. All of the key topics are covered, and detailed explanations are included for each of the answers. •Assessment and patient care interventions occur at least every two hours for the patient in non-violent/non-self- A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Wrist restraints Gait belt The nursing assistant applies a prescription The nurse is caring for a client admitted to the emergency room after a fall. Mummy restraints A client with diabetes mellitus has a prescription Grasp wrist of glove with opposite gloved hand, peel off (inside out) 01. Place the client in wrist restraints at night. A health care provider has written a prescription for wrist. Emphysema. Assign the client to a room closer to the nurse’s station. A nurse is providing teaching to a client who has a prescription for disulram. You have the right to be free any time from restraints unless medically needed. Notify the client’s provider. The doctor gives the reason for the restraint, what body part to restrain, what to use, and how long to use it. Request a prescription for a psychotropic medication. A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10 mg from the single-dose vial. Administer an antidepressant. prevent the development of a wound infection. b. Developing a plan of care for a school aged whose family is homeless, what is the priority? Child has inflamed fissures at the corners of her mouth. After obtaining a prescription for restraints from the provider which of the following actions should the nurse take? 10. Emphysema to the patient’s plan of care • Implemented in accordance with hospital policy and State law • Must be in accordance with the . Skin integrity . and back of the head that are common in Chinese culture and is called as syndromes of Wind. A nurse is caring for a client who has schizophrenia and is experiencing delusions. C. The provider prescribes soft wrist restraints. Retrospective chartaudit C. This section of the Texas Board of Nursing (BON or Board) website contains nursing practice topics and various resources for vocational nurses (LVNs), registered nurses (RNs), advanced practice registered nurses (APRNs), and those who work with licensed Place in order of priority, which clients the nurse will visit first to last. Keep the television on at night. Care is provided based on the assessed needs of the patient. Board staff receive phone calls and emails regularly regarding nursing practice issues and questions. The client has a history of physical violence. It argued that mandating a pharmacist’s review of a resident’s medical record will increase the time pharmacists spend in a facility, thus increasing facilities’ costs. unapproved physical restraints upon a client, [ ]; and/or c) [Withdrawn] 3. 13(g) (PDF). The nurse is preparing to leave the clients room following a dressing change. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S. Glucosamine 17. Which of the following actions should the nurse take? a. 1991, c. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. clients’ right to receive care. Peripheral pulses C. d. o A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Secure restraints with a square knot. O Tie the restraints to the side rail. The client suddenly cries out, his neck twists to one side, and his eyes appear to roll back in the sockets. Which of ¾ If a facility has residents who need to be restrained, the facility must have an ongoing systemic gradual restraint reduction program in place. X-rays reveal that the client has several fractured bones in the foot. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take? Document the client's behavior once every hour. A nurse is caring for a client who has a prescription for wrist restraints. To which of the following parts of the bed should the nurse secure the restraints? 16. Evaluate the client’s circulation once per shift after application. Securing Higher Grades Costing Your Pocket? Book Your Assignment at The Lowest Price Now! A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. “I will apply tapes over frayed areas of electrical cord. providing a high level of sensory stimulation Monitoring of patients in restraints will be performed by a staff member who has completed the required restraint training and competency assessment. Administer prescribed PRN lorazepam and apply soft wrist restraints. Rationale: The use of restraints without padding can abrade the client's skin, resulting in client injury. What should the nurse do when applying this type of restraint? Check the site of restraint every 30 mins General Nursing Practice Information. Prospective chartaudit B. be written as a standing order or on an as needed Hospital Restraint/Seclusion Deaths: 42 CFR § 482. In most circumstances, the client is an individual but in some circumstances (for example, in practice settings where family-centred care occurs) the client can include family members STNA Practice Test. Diabetes B. Answer . Alert the charge nurse to ensure that there is a nurse provided for each client in the assignment. A nurse has a prescription to apply wrist restraints to maintain client safety. Which of the following assessments should the nurse perform first? A. Denvr Blvd, Edison NJ (08820) Phone: +1-385-722-5334 patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term care hospital (LTCH) quality measures and resource use measures. B. A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. Which of the following actions should the nurse take? (Select all that apply. Complete an incident report. What action should be implemented by the nurse? Elevate the foot of the bed. By law, SNFs must develop a plan of care (care plan) for each resident. A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Nurse is caring for a client who has a mutation of the BRCA2 gene, client states she A nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints Which of the following actions should the nurse take? a. 14. of a physician or other LIP who is responsible for the care of the patient, and authorized by policy and State law • Orders for restraints must . The nurse is caring for a client with influenza. A client receiving IV chemotherapy and the infusion pump is alarming. Emphysema What are restraints? A restraint is anything that prevents or limits a patient from being able to move their arms, legs or body freely. To which of the following parts of the bed should the nurse secure the restraints? c. Which of the following actions should the nurse take? O Remove the restraints every 3 hr. . Nursing Care for the patient in Non-violent restraints •Patient's need for toileting, food and nutrition, hygiene, personal and medical care including mental, and neurological status will be met while in restraints. 13(g), Death Reporting Requirements, all patient deaths associated with restraint or seclusion (except 2-point soft wrist restraints that must be recorded in an internal hospital log or other system) in a hospital are required to be reported to the Centers for Medicare & Medicaid 3. The client is allergic to penicillin B. The client has an implanted defibrillator 9. Postoperative carepolicy D. Client B, a 60-year-old client who is visually impaired and who is post-op day three after hernia surgery. The nursing staff decides that the client should have restraints placed for safety. The client has a history of alcohol use disorder D. Elbow restraints B. You have the right to take part in this process and family members can help with your care plan with your permission. O. A nurse who has special training in using restraints can begin to use them. Apply padded portion of the restraint around the client's wrist. 07 Restraints The nurse is caring for a client with watery diarrhea following a When the nurse receives an order or prescription for a treatment or procedure that is questionable in terms of client appropriateness and safety, the nurse as the nurse manager of care, contacts the person who has prescribed the treatment or procedure, and they also clarify and verify all questionable orders. neck. Client A, a 78-year-old male client who recently had a hip fracture and who suffers from Parkinson’s disease. Physically restraining a patient during surgical procedures is utilized to place the patient in a proper surgical position, and to avoid sudden involuntary movements during surgery. Evaluate the client’s circulation once per shift after application A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. 40. Timoptic should be used with caution in the client with a history of: Diabetes. Select all that apply. The nurse should recognize that this medication can result in an adverse interaction when taken with which of the following over-the-counter supplements? Answer: B. The client has a closed-suction drain extending out of the wound. John's wort. 16. 2. Physicians who order chemical or physical restraints should: Use best professional judgment to determine whether restraint is clinically indicated for the individual patient. ”- no more than 120 degrees e. View complete question ». order . Skin Integrity 9. ¾ If a restraint is used, it must be the least restrictive for the least amount of time – consider short-term or time-limited orders. A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist. Gastric ulcers C. O Remove one restraint at a time. D. 13(g), Death Reporting Requirements, all patient deaths associated with restraint or seclusion (except 2-point soft wrist restraints that must be recorded in an internal hospital log or other system) in a hospital are required to be reported to the Centers for Medicare & Medicaid When the nurse receives an order or prescription for a treatment or procedure that is questionable in terms of client appropriateness and safety, the nurse as the nurse manager of care, contacts the person who has prescribed the treatment or procedure, and they also clarify and verify all questionable orders. 9. Tea and coffee are restricted on the day of the test. Try our free STNA practice test. Assist the client out of bed to a chair. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. 851-063-0030Authorized Duties and Standards for Certified Nursing Assistant 1 (CNA 1) (1) Under the supervision and at the direction of a licensed nurse, the CNA may provide care and assist clients with the following tasks: (a) Tasks associated with collaboration with health care team: (D) Orienting other nursing assistants to workflow and G is a client with fluctuating levels of consciousness, disturbed orientation, and perceptual alterations. prevent fluid from accumulating in the wound. ” 43. Which of the following actions should the nurse take? 5. Care will include: -Offering liquids and nutrition -Toileting Nursing documentation for restraints. c. Attach the restraints securely to the side rails of the client's bed. You need to document the rationale for why the patient is in restraints, how long they have been in restraints, what care was offered to the patient, what care was provided to the patient, and all at what times. The test will take between 45 minutes and 2 hours. St. Which of the following interventions should the nurse include in the plan of care? answer Initiate one-to-one observation. Timoptic should be used with caution in the client with a history of: A. Restraints should not cause you pain or harm. Which intervention should the nurse implement at this time to prevent the client from becoming violent? A. A client in wrist restraints who has a sitter in the room. In order to maintain client safety, the nurse should first: 1. Full arm restraints C. a. A client who is one day post chest tube insertion for pneumothorax. 5. Contact the physician and request a prescription for soft wrist restraints. Choose the instructions that the nurse places on the list. Comfort Level B. Which of the following actions should the nurse take? Answer: Pad the client's wrist before applying the restraints. 4. The nurse should protect the client from harm, but restraints can result in unapproved physical restraints upon a client, [ ]; and/or c) [Withdrawn] 3. 3. headache. Which of the following actions should the nurse take? Pads the client wrist before applying the restraints. A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. 1. Mummy restraints. What should the nurse do when applying this type of restraint? Select all that apply. Those nurses who worked in surgical intensive care units and emergency departments and had in-service training used The patient has the right to safe implementation of restraint or seclusion by trained staff. Apply the restraints to allow as little movement as possible d. Tie the tales of the wrist restraints to the frame of the bed using a square knot. A nurse has an order from a primary health-care provider to apply wrist restraints to maintain a patient’s safety. Which of the following actions should the nurse take? - Remove one restraint at a time 15. Encourage the client to participate in group activities. Nurse is caring for a client who has a mutation of the BRCA2 gene, client states she a. The provider prescribes wrist restraints for the client's safety. Which of the following actions should the nurse take? O Secure restraints with a square knot.

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