padding on a restraint helps

NCLEX-PN

Next Generation Nclex Questions Overview 3.0 ATI Quizlet

1. Why is padding on a restraint helpful?

A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
B. To help the client feel more secure.
C. To keep infection and wounds at bay.
D. To keep restraints in place.

Correct answer: A

Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.

2. A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

A. Telling the client that she needed to ask these questions before signing the informed consent for surgery
B. Contacting the surgeon and requesting that she visit the client to answer her questions
C. Informing the client that she has the right to cancel the surgical procedure if she wishes
D. Telling the client that it is her surgeon's responsibility to explain the procedure

Correct answer: B

Rationale: Informed consent is the authorization by a client or a client's legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client's part, the nurse has the obligation to contact the surgeon. Choice A is incorrect as the client should be allowed to ask questions even after signing the consent for surgery. Choice C is not the most appropriate response, as the primary concern is to address the client's lack of comprehension. Choice D is inaccurate, as while it is the surgeon's responsibility to explain the procedure, in this scenario, the nurse should take immediate action to ensure the client's understanding. Requesting the surgeon to visit and answer the client's questions is the most appropriate response in this situation, as it directly addresses the client's concerns and ensures proper informed consent is obtained.

3. What is the most appropriate feeding method for a client who is unable to swallow?

A. Nothing by mouth
B. Nasogastric feedings
C. Clear liquids
D. Total parenteral nutrition

Correct answer: B

Rationale: Nasogastric feedings are the most appropriate feeding method for a client who is unable to swallow. Providing nothing by mouth can lead to nutritional deficiencies, while clear liquids might cause aspiration. Total parenteral nutrition is not necessary if the gastrointestinal tract is functional. Nasogastric feedings are preferred as they can safely provide nutrition without the risks associated with not eating or aspirating.

4. When should the biohazard emblem be affixed to containers according to the orientation nurse educator reviewing the biohazard legend with a class of new employees?

A. when there is presence of blood and body fluids.
B. when there is the need for droplet precautions.
C. when there is contact isolation.
D. when there is the potential for airborne transmission.

Correct answer: A

Rationale: The correct answer is 'when there is presence of blood and body fluids.' When handling body substances like blood and body fluids, the risk of transmission of infections increases. Federal regulations mandate warning labels on containers to alert employees and waste collectors. The biohazard emblem consists of a three-ring symbol overlaying a central concentric ring. Blood, wound drainage, feces, and urine are examples of body fluids that can transmit infections and diseases to others. The other choices, B, C, and D, are incorrect because the presence of the biohazard emblem is specifically linked to the handling of blood and body fluids, not to droplet precautions, contact isolation, or airborne transmission.

5. How should an infant be secured in a car?

A. To hold the infant while sitting in the middle of the back seat of the car
B. To place the infant in the front seat in a rear-facing infant safety seat if the car has passenger-side air bags
C. To place the infant in a booster seat in the front seat with the shoulder and lap belts secured around the infant
D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat

Correct answer: D

Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants. Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.