A charge nurse is reinforcing teaching for a newly licensed nurse about how to apply wrist restraints for a client.
Which of the following actions should the charge nurse identify as an indication that the nurse understands the instructions?
Ties the straps of the restraints in a double knot.
Ties the restraints to the side rails.
Places the padding of the restraints against the client's bony prominences.
Inserts one finger between the client's wrist and the restraint.
The Correct Answer is B
Choice A rationale:
Using a fire extinguisher should not be the nurse's first action in this situation. The nurse's priority is to ensure the safety of the clients and staff in the vicinity. Attempting to use a fire extinguisher might not be effective and can potentially cause harm, especially if the fire spreads quickly.
Choice B rationale:
Activating the fire alarm is the nurse's priority in this situation. By activating the fire alarm, the nurse can alert everyone in the facility about the fire, ensuring that people are aware and can evacuate safely. This action initiates the facility's fire response protocol, leading to a quicker and organized response to the emergency.
Choice C rationale:
Moving clients to safety is important, but it is not the nurse's immediate priority in this situation. Activating the fire alarm should be done first to ensure that everyone in the facility is aware of the danger, and then the nurse can assist in moving clients to safety if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Drinking something cold can lower the oral temperature temporarily. When a person consumes something cold, the blood vessels in the mouth can constrict, leading to a lower temperature reading. However, it's important to note that this effect is temporary.
Choice B rationale:
Exercising can increase blood circulation and raise body temperature. However, immediately after intense physical activity, the body might start sweating, leading to a temporary drop in temperature. Prolonged or moderate exercise, on the other hand, generally increases body temperature.
Choice C rationale:
An outdoor temperature of 99°F does not directly affect body temperature. Body temperature is regulated internally and does not fluctuate based on external temperatures unless the person is exposed to extreme conditions for a prolonged period.
Choice D rationale:
A cold climate might lower skin temperature, but it does not necessarily reduce the body's core temperature significantly. The body has mechanisms to conserve heat in colder environments.
Choice E rationale:
Physical inactivity can lower body temperature, especially in situations where the person is sedentary for an extended period. Reduced physical activity can slow down metabolic processes, leading to a lower body temperature.
Correct Answer is D
Explanation
Choice A rationale:
Wearing a mask when entering the client's room is not specifically required for contact precautions. Masks are primarily used for airborne precautions or when caring for patients with respiratory infections spread through droplets.
Choice B rationale:
Removing potted plants from the room may be a good practice for infection control, but it is not a specific action mandated by contact precautions. Contact precautions primarily focus on preventing the transmission of infections through direct or indirect contact with the patient or their environment.
Choice C rationale:
Allowing the client to leave the room every 2 hours is not a recommended practice for contact precautions. Patients under contact precautions should ideally stay in their rooms to prevent the spread of infections to others in the healthcare facility.
Choice D rationale:
When caring for a client under contact precautions, it is essential to dedicate equipment and supplies for their use exclusively. This helps prevent the spread of infections to other patients or healthcare workers by avoiding the contamination of shared items.
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