Safety and Infection Control Practice Question
Question
The nurse is caring for a client with pneumonia and is focused on restraints scenario 7. Which nursing action is most appropriate?
Answer choices
- A. Delay assessment until the next scheduled round if the client is not calling for help.
- B. Delegate the clinical assessment and nursing judgment to assistive personnel.
- C. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
- D. Try less restrictive measures first and monitor circulation, skin, and safety after application.
Correct Answer
D. Try less restrictive measures first and monitor circulation, skin, and safety after application.
Explanation
The priority action for restraints is to try less restrictive measures first and monitor circulation, skin, and safety after application. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.
Question details
- Difficulty: hard
- Domain: Safety and Infection Control
- Objective: restraints