When caring for a patient who has an arm or leg restraint in ...

[OSWALD]

When caring for a patient who has an arm or leg restraint in place, how often will the nurse remove the restraint?
 
  a. Every 15 minutes
  b. Every 30 minutes
  c. Every hour
  d. Every 2 hours

Question 2

If a patient is receiving radiation using gamma rays, the nurse would be watching for which of the following?
 
  a. Severe pain during administration
  b. Development of an allergy to shellfish
  c. Severe burns or internal injury
  d. Confusion and lethargy

[CharlieArnold]

Answer to Question 1

D
Restraints should be removed at least every 2 hours (Joint Commission on Accreditation of Healthcare Organizations JCAHO, 2004). If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patient's position, offer nutrients, perform full ROJM, and toilet and exercise the patient. After application, evaluate the patient's condition for signs of injury every 15 minutes. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. If the patient shows no sign of impaired circulation or other complications, the restraint does not need to be removed at this time. If the nurse restrains a patient in an emergency situation because of violent or aggressive behavior, this presents an immediate danger; a face-to-face physician assessment is needed within 1 hour to determine the patient's need for the restraint.

Answer to Question 2

C
Gamma rays pose the greatest health risk because the waves penetrate deeply, causing severe burns and internal injury. Radiation does not cause patients to develop an allergy to shellfish and is painless during administration. Confusion and lethargy are not known side effects of radiation.

[OSWALD]

Thank you

[CharlieArnold]

No problemo