A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?

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Question 1 of 4

A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?

Correct Answer: A

Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.

Question 2 of 4

A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

Correct Answer: D

Rationale: Correct! A calcium level of 8.0 mg/dL indicates hypocalcemia. Hypocalcemia can lead to increased neuromuscular excitability, manifesting as tingling of the extremities. Choices A, B, and C are incorrect findings associated with other electrolyte imbalances or conditions and are not typically related to hypocalcemia. Constipation is commonly seen in hypokalemia, absent deep-tendon reflexes are associated with hypermagnesemia, and nausea and vomiting are more indicative of hypercalcemia.

Question 3 of 4

A nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 4

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: The Z-track method should be used to administer IM injections in obese clients to prevent medication from leaking into subcutaneous tissue. Using a longer needle (1.5 inches) ensures that the medication reaches the muscle mass adequately. Choice C is incorrect because the deltoid muscle is not ideal for IM injections in obese clients due to inadequate muscle mass. Administering the injection at a 90° angle (perpendicular to the skin) is recommended for IM injections to ensure proper delivery into the muscle.

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