ATI Nur 231 Fundamentals Exam

Extract:

Question 1 of 5

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

A. Obtain the provider's prescription renewal every 72 hr. B. Document restraint checks and client status every 2 hr. C. Implement passive range-of-motion exercises. D. Educate the client's family about restraint use. E. Release the restraint and reposition the client every 4 hr.

Correct Answer: A,B,C,D

Rationale:
Correct
Answer: A, B, C, D

Rationale:
A: Obtaining provider's prescription renewal every 72 hr ensures ongoing assessment of the necessity for restraints.
B: Documenting restraint checks and client status every 2 hr ensures monitoring for any adverse effects and compliance with regulations.
C: Implementing passive range-of-motion exercises prevents contractures and maintains joint mobility in an immobile client.
D: Educating the client's family about restraint use promotes understanding and compliance, reducing the risk of complications.

Summary of Incorrect

Choices:
E: Releasing the restraint and repositioning the client every 4 hr may not be appropriate as it can lead to potential harm or injury if the client is agitated or at risk of falling.
F:
G:

In summary, the correct interventions focus on monitoring, prevention of complications, and education, while the incorrect choices may pose risks to the client's safety.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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ATI Nur 231 Fundamentals Exam | Nurselytic

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