A newly licensed nurse is applying prescribed wrist restraints on a client.
Which of the following actions should the nurse take?

Anticipate removing the restraints every 4 hr.

Ensure four fingers fit under the restraints to prevent constriction.

Secure the restraints using a quick-release tie.

Secure the restraints to the lowest bar of the side rail.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C. Secure the restraints using a quick-release tie.

Choice A rationale: Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.

Choice B rationale: Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.

Choice C rationale: Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.

Choice D rationale: Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.

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Correct Answer is D

Explanation

The correct answer is choice D.

Choice A rationale:

Assisting the client to a side-lying position is not necessary when administering nasal decongestant drops. The client can be in an upright position or slightly tilted back.

Choice B rationale:

Holding the dropper 2 cm (1 in) above the naris is not a standard guideline for administering nasal decongestant drops. The dropper should be inserted into the nostril without touching the inside of the nostril to avoid contamination.

Choice C rationale:

Instructing the client to stay in the same position for 2 min is not necessary. After the administration of the nasal decongestant drops, the client can resume their normal activities.

Choice D rationale:

Telling the client to blow her nose gently before the instillation is the correct action. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.

A. Regulates and monitors laws set by the Nurse Practice Act. B. Establishes a protocol for care to provide for a specific health problem. C. Promotes excellence in nursing education. D. Determines competencies for the nurses to achieve before licensure.

Correct Answer is A

Explanation

Choice A rationale:

The role of the Board of Nursing (BON) includes regulating and monitoring laws set by the Nurse Practice Act. The BON ensures that nurses practice within the legal framework established by the state's Nurse Practice Act, which defines the scope of nursing practice, licensing requirements, and standards of care. This helps maintain the safety and quality of nursing care in the state.

Choice B rationale:

Establishing a protocol for care to provide for a specific health problem is typically not within the role of the Board of Nursing (BON). The BON focuses on setting and enforcing broader standards of nursing practice and licensure requirements, rather than creating specific protocols for individual health problems. Protocols are often developed by healthcare institutions or professional organizations.

Choice C rationale:

Promoting excellence in nursing education is an important goal, but it is not the primary role of the Board of Nursing (BON). While the BON may have some involvement in accrediting nursing education programs, its primary responsibility is to regulate nursing practice and ensure public safety through licensing and adherence to the Nurse Practice Act.

Choice D rationale:

Determining competencies for nurses to achieve before licensure is a role of the Board of Nursing (BON). The BON sets the standards and requirements that nurses must meet to become licensed, which includes establishing the necessary competencies and qualifications. This helps ensure that nurses entering the profession are adequately prepared to provide safe and competent care.

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A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing an in-service to a group of newly licensed nurses on standards of practice and the role of the Board of Nursing (BON). Which of the following information should the nurse include?

Correct Answer is A

Explanation

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A newly licensed nurse is applying prescribed wrist restraints on a client.
Which of the following actions should the nurse take?