which of these devices is considered a protective device rather than a restraint

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. Which of these devices is considered a protective device, rather than a restraint?

A. A mitten on the hands to prevent scratching
B. A mitten on the hands to prevent the person from pulling their IV out
C. A side rail to prevent the patient from falling
D. A soft wrist restraint to prevent the patient from pulling their IV tubing

Correct answer: A

Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.

2. Which of the following is a function of risk management?

A. To consider the problems that arise if errors happen and their effects on the healthcare environment
B. To identify how nursing care responds to specific client problems
C. To view clients as customers and decide what actions will provide a satisfying healthcare experience
D. To analyze physician-nurse relationships and determine where collaboration efforts can improve

Correct answer: A

Rationale: The function of risk management in healthcare is to assess and address potential risks that could lead to errors and their effects on the healthcare environment. This involves identifying, evaluating, and prioritizing risks to minimize their impact and prevent adverse outcomes. Choice A is correct because it aligns with the core purpose of risk management in healthcare. Choices B, C, and D are incorrect as they do not directly relate to the primary focus of risk management, which is the proactive management of risks to ensure patient safety and quality care.

3. A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?

A. Contact the physician immediately
B. Administer a bolus of 50 cc of D20W through the IV
C. Administer 10 units of regular insulin
D. Give the client 6 oz. of orange juice

Correct answer: D

Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.

4. An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?

A. Treat workers with pulmonary fibrosis.
B. Teach about symptoms of lung disease.
C. Require the use of protective equipment.
D. Monitor workers for coughing and wheezing.

Correct answer: C

Rationale: Prevention of lung disease requires the use of appropriate protective equipment such as masks to reduce exposure to inhaled dust, which is a significant risk factor for lung disease. Teaching about symptoms of lung disease, treating workers with pulmonary fibrosis, and monitoring for coughing and wheezing are important actions for early recognition and treatment of lung disease. However, the most effective strategy to prevent lung damage in this scenario is to require the use of protective equipment to minimize exposure to harmful substances.

5. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:

A. Go get a blood pressure check within the next 15 minutes
B. Check blood pressure again in two (2) months
C. See the healthcare provider immediately
D. Visit the healthcare provider within one (1) week for a BP check

Correct answer: A

Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.