NCLEX Question of the Day – 01.20.17 An elderly client, who is not oriented to time, place, or person, had a total hip replacement. The client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. The client has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the nurse are appropriate? Select all that apply. 1. Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every 2 hours. 2. Document the type of restraint used and assess the need for continued use. 3. Tie the restraints to the side rails of the bed. 4. Obtain a new physician order for the restraint every 12 hours. 5. Observe for correct placement of restraints. 6. Tie the restraints in a quick-release knot.
3 thoughts on “NCLEX Question of the Day – 01.20.17”
Jarrett 1 is correct the patient may not be oriented to time, place or person could still know the sensation of needing to use the restroom. And when a patient if in restraints you need to provide ROM to the patients wrist and arm every 2 hours. And some places to have restraints that you need to tie, so its good to know the proper knot
1 is wrong because the patient is not oriented and she would not b getting ROM so early postop. 3 the proper restraints don’t need to tie.
I say 2,4 &5