when using restraints for an agitatedaggressive patient which of the following statements should not influence the nurses actions during this interven
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2024

1. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

Correct answer: C

Rationale: The correct answer is C because the patient's voluntary or involuntary status should not impact the nurse's actions when using restraints. The use of restraints should be based on the patient's behavior and the need to ensure their safety and the safety of others. Choices A, B, and D are important factors that should influence the nurse's actions. The institution's restraints/seclusion policies provide guidelines on the appropriate use of restraints, the patient's competence helps determine their understanding and ability to control their behavior, and the patient's nursing care plan guides the overall care provided, including the use of restraints if necessary.

2. 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.

3. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

Correct answer: D

Rationale: When a charge nurse observes repeated failure in a staff member's performance, it is essential to address the issue directly. Choice D is the correct answer as it involves discussing the behavior with the assistive personnel (AP) while reinforcing expectations. This approach helps in clarifying the expected standards, setting accountability, and providing an opportunity for improvement. Choices A, B, and C are incorrect. Ignoring the behavior (Choice A) does not address the problem and can lead to continued substandard care. Reassigning the AP (Choice B) may not solve the issue and can potentially transfer the problem to another area. Reporting the behavior to the manager (Choice C) without directly addressing it with the AP first may not promote a constructive approach to resolving the issue.

4. What is the most appropriate safety measure for a client using home oxygen?

Correct answer: B

Rationale: The correct answer is to ensure oxygen tanks are kept upright at all times. This is important to prevent the tanks from falling over, which can lead to injuries or tank damage. Choice A is incorrect because oxygen tanks should not be stored in a closet when not in use, as this can lead to poor ventilation and potential hazards. Choice C is incorrect because smoking near oxygen tanks poses a significant fire risk. Choice D is incorrect because while it is important to keep oxygen equipment away from heat sources, ensuring the tanks are kept upright is a more critical safety measure.

5. A nurse is teaching a client who has peripheral arterial disease (PAD) about exercise recommendations. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Stop exercising if pain occurs.' In peripheral arterial disease (PAD), it is crucial to avoid exercising to the point of pain as this may worsen the condition and lead to complications. Exercising to the point of pain can result in inadequate blood flow to the extremities, causing further damage. By stopping exercise if pain occurs, the client can prevent exacerbating their condition. Choices A, C, and D are incorrect because exercising to the point of pain, limiting exercise to once per week, and avoiding walking altogether are not recommended strategies for managing PAD and could potentially harm the client.

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