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    Ati Rn comprehensive predictor 2023 proctored exam

    A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

    Explanation & Rationale

    A. "I should visually monitor the client continuously when in mechanical restraints." Continuous visual monitoring is required to ensure the client’s safety, monitor for distress or injury, and assess the ongoing need for restraints. This is a key safety standard in the use of mechanical restraints. B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." Skin integrity must be assessed much more frequently, typically every 15 to 30 minutes, to prevent injury or pressure-related complications while the client is restrained. C. "I should expect the provider to evaluate the client within 4 hours of restraint application." For adults, a provider must evaluate the client within 1 hour of the initiation of mechanical restraints. A 4-hour delay does not meet safety or legal standards. D. "I should ask the provider to write a prescription for mechanical restraints as needed." PRN (as-needed) prescriptions for restraints are not permitted. Each use must be justified, time-limited, and based on the client’s immediate behavior or condition.

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