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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Atrial fibrillation with a rapid heart rate can lead to decreased cardiac output and compromised blood flow, which can have serious consequences, including stroke and heart failure. Therefore, this client requires immediate attention to assess and manage the cardiac rhythm.
While the other clients also have significant health concerns, they are not as acutely life-threatening as a new onset of atrial fibrillation with a high heart rate. Prioritizing care based on the urgency and severity of the condition is crucial in the emergency department setting.
Correct Answer is ["C","D","E"]
Explanation
The correct answer is to select the following three findings that require immediate follow-up:C. Urticaria,D. Blood pressure at 1630, andE. Report of dysphagia.
Choice A rationale:
“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.
Choice B rationale:
“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.
Choice C rationale:
“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis.Immediate follow-up is necessary to prevent further complications.
Choice D rationale:
“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg).This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.
Choice E rationale:
“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis.This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.
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