NCLEX SATA Quiz: Safety and Infection control

1. An elderly client, who is not oriented to time, place, or person, had a total hip replacement. The client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. The client has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the nurse are appropriate? Select all that apply.*
- 1. Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every 2 hours.
- 2. Document the type of restraint used and assess the need for continued use.
- 3. Tie the restraints to the side rails of the bed.
- 4. Obtain a new physician order for the restraint every 12 hours.
- 5. Observe for correct placement of restraints.
- 6. Tie the restraints in a quick-release knot.
2. The client has a new order for placement of a Foley catheter due to urinary retention. Which of the following should the nurse do before starting the procedure? Select all that apply.*
- 1. The nurse should confirm the client’s identity, because a procedure requires proper identification.
- 2. The nurse should confirm the client’s medical record number via the wristband and order.
- 3. Ask the client his or her name only, because this is a procedure and not a medication administration.
- 4. The nurse should confirm the client’s name via the wristband and order.

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