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NCLEX notes/ uworld LAPTOP

Terms in this set (769)

Accidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2).
(Option 1) Assessing the respiratory system is important but isAccidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2).
(Option 1) Assessing the respiratory system is important but is not the priority action. Rescue breathing should not be delayed, as sedation significantly depresses respiration. Assessment is important for a new problem but not for an existing one, especially if delayed care can lead to life-threatening complications.
(Option 3) Another nurse can notify the health care provider. Oxygenation is the priority action.
(Option 4) While there is a risk for cardiac arrest, the nurse should support the client's airway and breathing to prevent arrest. A code blue should be initiated if cardiac arrest occurs. Rescue breathing should not be delayed, as sedation significantly depresses respiration.
A physical restraint is a device or method used to immobilize or limit physical mobility or body movement to prevent falls, injury to self or others, or removal of medical devices. The client situation, rather than the device, determines whether it is classified as a restraint. Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or examinations are not considered physical restraints and do not require authorization for use from a health care provider. Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest time possible once it is safe to do so.
The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps usinterm-754g a quick-release knot. It is used to protect a confused or disoriented client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily (Option 1).
Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following a procedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently (Option 5). Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint. The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained extremity.
(Option 2) Elbow restraints used as a protective device to temporarily immobilize a child (<30 minutes) to perform a medical, diagnostic (eg, drawing blood), or surgical procedure are not considered a physical restraint.
(Option 3) The use of full padded side rails in the raised position for clients during a seizure protects them from immediate injury; these are not considered a restraint.
(Option 4) An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint.