Author Question: A physician or health care provider orders that a confused and disoriented patient be placed in a ... (Read 48 times)

nummyann · **on:** Jul 22, 2018

A physician or health care provider orders that a confused and disoriented patient be placed in a full hand restraint because of excessive scratching of skin. The nurse acknowledges that:

A. restraints are used on an as-needed basis.
B. no orders or patient consents are needed.
C. restraints must be removed on a regular basis to allow for skin assessment, toileting, and nutrition.
D. an order for restraints may be used indefinitely until the patient no longer needs to be restrained.

Question 2

A patient's draining wound is pale and watery with a combination of plasma and red cells. The nurse appropriately documents the drainage as:

A. serous.
B. purulent.
C. sanguineous.
D. serosanguineous.

frejo · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Restraints are only used when other less restrictive measures fail to prevent interruption of therapies. The physician's or health care provider's orders are necessary. The need for restraints must be reevaluated every 24 hours.

Answer to Question 2

D
Purulent is thick, yellow, green, or brown, indicating the presence of dead or living organisms and white blood cells. Sanguineous is fresh bleeding. Serosanguineous is pale, more watery, and a combination of plasma and red cells, which may be blood streaked.