NCLEX PN Practice Test Practice Question
The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?
Correct Answer: D
Rationale: A vest restraint in the high-Fowler position (D) poses a risk of strangulation or asphyxiation due to the restraint slipping upward, requiring immediate intervention. Belt restraint in semi-Fowler (A), mitten restraints in side-lying (B), and wrist restraints in supine (C) are safer positions, assuming proper application and monitoring.
Unlock All Questions
Subscribe to Premium for full access to all practice questions, detailed rationales, and performance tracking.
Subscribe Now