Safety: Exam Questions With Correct Detailed Answers| Graded A+

It provides a means to steady a patient at the center of gravity. A gait belt is used to transfer a patient safely or as a safety measure to steady a patient who has poor balance. NAP or nurses may use a gait belt. - correct answers What is the purpose of a gait belt? It keeps patients from ambulating too fast by holding onto them. It measures the distance a patient has ambulated by counting steps. It provides a means to steady a patient at the center of gravity. It identifies patients who are at risk for a fall and require assistance. It is a type of restraint used as a safety measure. Notify the health care provider for follow-up evaluation. When a restraint is used for violent or self-destructive behavior, a licensed health care provider must evaluate the patient in person within 1 hour of the initiation of restraints and orders obtained. Restraints should be tied to the movable frame of the bed so if the position of the head of bed is changed, the patient's extremity will not be compromised. Restraints should never be tied to the side rail. Restraints should be secured with a quick-release tie in case of an emergency. The restraints should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time or have staff assistance. - correct answers A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the assistance of security, the charge nurse places wrist restraints on the patient. What would be a priority action at this time? Notify the health care provider for follow-up evaluation. Tie the restraint straps in a knot so the patient does not get loose. Tie the restraints to the bedside rail or frame of the wheelchair. Assess, but avoid removing the restraints every 2 hours because the patient is violent. Suction the airway as necessary. The nurse should first use suction equipment if necessary to clear food from the airway and position the patient in the high-Fowler's position or, if unable to do so, position the patient on the patient's side. If choking occurs repeatedly, stop feeding the patient and notify the health care provider. Provide oxygen if the patient's color has failed to return to normal. Offering the patient water may only increase choking, because thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated. As a preventive measure, the nurse should allow the patient to rest throughout feeding. - correct answers The patient begins to cough and choke while the nurse is feeding him. What should the nurse do? Give the patient some water. Allow the patient to rest. Suction the airway as necessary. Notify the health care provider immediately. Elbow restraint. Elbow restraints are used to prevent a patient (usually a child) from reaching the head and face area to pull at stitches and tubes or scratch at skin irritations. A belt restraint secures a patient in bed or on a stretcher. An extremity/limb restraint (wrist or ankle) may be used to immobilize one or all extremities. A mitten restraint is a thumbless mitten device to restrain a patient's hands. It is used to prevent the use of fingers to scratch the skin, remove dressings, or dislodge equipment, yet allows more movement than a wrist restraint. - correct answers A nurse is determining which type of restraint to apply to a toddler who recently had facial surgery and is pulling at her sutures and oxygen tubing and rubbing her face. Which type of restraint would likely be the least restrictive and most effective? Belt restraint. Extremity restraint. Mitten restraint. Elbow restraint. Initially, provide a restraint-free environment. The standard of care for institutionalized older adults is avoidance of mechanical restraints except as needed under exceptional circumstances and only after all other reasonable alternatives have been tried. Creating fear in the patient and stating restraints will be used as a punishment can be considered assault. The patient should be provided with the least restrictive environment, and close monitoring would be wise. Restraints are to be used only after all other reasonable alternatives have been tried. If the nurse waits until the patient has actually fallen, the patient could sustain an injury. Although restraints are to be used only after all other reasonable alternatives have been tried, it is unreasonable to wait until the patient sustains a fall. - correct answers What should the nurse do prior to applying physical restraints? Move the patient to a room without a roommate and away from the nurses' station. Warn the patient that restraints will be used if he or she does not cooperate. Initially, provide a restraint-free environment. Wait until the patient has actually fallen. Restraints provide a reliable method to prevent falls without serious complications. The use of restraints is associated with serious complications, including pressure ulcers, constipation, urinary and fecal incontinence, and pneumonia. In some cases, restricted breathing or circulation has resulted in death. Loss of self-esteem and a sense of humiliation, fear, and anger are additional serious concerns. Side rails may be considered a restraint device when used to prevent the ambulatory patient from getting out of bed. Check agency policy. Using two fingers to check the fit of a restraint guarantees safe application and prevents neurovascular compromise. Restraints should not be attached to the bedside rails but should be attached to the portion of the bed frame that will move when the head of the bed is raised or lowered to prevent patient injury. - correct answers The nurse manager is reviewing the use of restraints during an in-service with the staff. Which of the following is inaccurate information that should not be included in the discussion? Restraints provide a reliable method to prevent falls without serious complications. Attach the restraint to the movable part of the bed frame. When all side rails are raised, this may be considered a form of physical restraint. Two fingers should be able to fit underneath the restraint. On the patient's strong (unaffected) side. During transfer, position the wheelchair on the same side of bed as patient's strong or unaffected side. This will best enable the patient to transfer safely and maximize the patient's ability. - correct answers A patient with left-sided weakness needs to be transferred to a wheelchair. On which side of the bed should the nurse place the wheelchair? On the patient's strong (unaffected) side. On the patient's weak (affected) side. Whichever side the patient prefers. Either side of the bed. Distal pulses. Temperature of the skin distal to the restraint. Sensation of the distal part of the extremity. Proper placement of the restraint. Color of skin distal to the restraint. The restraint should be checked at least every hour or according to agency policy for proper placement, and the patient should be evaluated for pulse, temperature, color, and sensation of the distal part of the extremities. The restraints should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time or have staff assistance. With regard to extremity restraints, routine assessment of the patient's blood pressure or character of respirations is unnecessary unless the patient's condition indicates otherwise. - correct answers The nurse checks the patient's extremity restraints hourly. What is the nurse looking for specific to this type of restraint? (Select all that apply.) Distal pulses. Whether the patient wants the restraints released. Temperature of the skin distal to the restraint.