A confused patient needs to have restraints applied to prevent ...

[savannahhooper]

A confused patient needs to have restraints applied to prevent him from pulling out his Foley catheter. Which of the following options can the nurse delegate to an unregulated care provider (UCP)?
 
  a. Applying restraints
  b. Obtaining a physician's order to restrain the patient
  c. Documenting the events that led to restraining the patient
  d. Evaluating the effectiveness of the restraints

Question 2

The nurse is helping the client to walk. Which of the following actions should the nurse take first?
 
  a. Help the client to sit at the side of the bed for one or two minutes.
  b. Support the client by using a gait belt.
  c. Assess the client's activity tolerance, strength, and balance.
  d. Ask a second nurse to be close by.

[xiaomengxian]

Answer to Question 1

A

Feedback
A Although the UCP can apply the restraints under the nurse's direction, he or she cannot document, evaluate, or take physicians' orders. The nurse is always responsible for assessment of patients' safety needs.
B A UCP cannot take physicians' orders.
C A UCP cannot document the events that led to restraining the patient.
D A UCP cannot evaluate the effectiveness of the restraints.

Answer to Question 2

C
The nurse assesses the client's activity tolerance, strength, coordination, and balance as well as orientation, and determines if there are any signs of distress that might preclude attempts at am-bulation.
Assessing the client is the first responsibility; then the nurse helps the client to sit at the side of the bed, allowing him or her to rest for one or two minutes to reduce the risk of orthostatic hypo-tension.
A gait belt is used to provide support for the client. However, the initial responsibility is to eval-uate the client's ability to walk.
The priority is for the nurse to assess the client's activity tolerance.