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 B

Explanation

The correct answer is Choice B: A client who has a family history of breast cancer is scheduled for a mammogram.

Choice A rationale:

Receiving an influenza vaccination is an example of primary prevention, which aims to prevent the onset of disease.

Choice B rationale:

Scheduling a mammogram for a client with a family history of breast cancer is an example of secondary prevention. Secondary prevention involves the early detection and treatment of disease to reduce the impact of the disease. Mammograms help in the early detection of breast cancer, which can significantly improve treatment outcomes.

Choice C rationale:

Not scheduling tests for an asymptomatic client does not relate to secondary prevention. Secondary prevention involves screening and early detection of diseases in at-risk populations.

Choice D rationale:

Scheduling an echocardiogram for a client with heart failure is an example of tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness or injury that has lasting effects by helping patients manage long-term, complex health problems.

A. Justice. B. Fidelity. C. Veracity. D. Autonomy.

Correct Answer is D

Explanation

Choice A rationale:

While the principle of justice is essential in healthcare, it does not directly address the client's decision to proceed with elective surgery or not. Justice pertains more to the fair allocation of resources and the equitable treatment of individuals, which may not directly apply to the client's autonomy in this situation.

Choice B rationale:

The principle of fidelity relates to keeping promises and being faithful to commitments, but it may not be the primary ethical principle to consider in this situation. The client's decision to proceed with elective surgery is primarily a matter of personal autonomy, and the nurse should prioritize respecting the client's autonomy over fidelity.

Choice C rationale:

Veracity is the principle of truthfulness and honesty in communication, but it does not take precedence over the client's autonomy in this context. While it is important for the nurse to provide honest information, the client's autonomous decision to proceed with or decline surgery should be respected regardless of the nurse's communication of truthful information. .

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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

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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?