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

Choice A rationale:

The nurse should not inform the client of the need to pre-pay for the consent of authorization. Precertification for surgery is related to obtaining approval from the client's insurance provider and not about pre-payment.

Choice B rationale:

Contacting the client's insurance carrier to obtain authorization is the correct action to take when obtaining precertification for surgery. Many insurance companies require pre-authorization for surgical procedures to ensure coverage and to confirm that the procedure is medically necessary. This step is essential to prevent financial burdens on the client and ensure they have coverage for the surgery.

Choice C rationale:

Notifying the provider to obtain approval for the surgery is not the nurse's responsibility in the context of precertification. The primary responsibility lies with obtaining approval from the client's insurance carrier.

Choice D rationale:

Witnessing the client sign the surgical consent form is an essential step in the surgical preparation process but is not the same as obtaining precertification. Precertification involves confirming insurance coverage and approval for the surgery, which is the responsibility of the insurance carrier, not the client's consent.

A. Budesonide 6 mg PO daily B. BMI: 16 C. History of type 2 diabetes mellitus D. New diagnosis of Crohn's disease E. Hematocrit (Hct): 47% F. Hemoglobin (Hgb): 16 g/dL G. Potassium: 3.6 mEq/L

Correct Answer is ["A","B","C","D"]

Explanation

Findings that Could Increase Susceptibility to Infection:

Budesonide 6 mg PO daily:
- Explanation: Budesonide is a corticosteroid used to reduce inflammation, often prescribed for conditions like Crohn's disease. While it helps manage inflammation, corticosteroids also suppress the immune system. This immunosuppressive effect can increase the client's susceptibility to infections.
BMI of 16:
- Explanation: A BMI of 16 is considered underweight. Malnutrition or being underweight can weaken the immune system, making a person more susceptible to infections because their body lacks the necessary nutrients and energy to support immune function.
History of Type 2 Diabetes Mellitus:
- Explanation: Diabetes, particularly if not well-controlled, can impair the immune system and increase the risk of infections. High blood sugar levels can hinder the function of immune cells, making it easier for infections to develop and harder for the body to fight them.
New Diagnosis of Crohn's Disease:
- Explanation: Crohn's disease is an inflammatory bowel disease that causes inflammation of the digestive tract. This chronic inflammation can affect the body's ability to absorb nutrients, leading to nutritional deficiencies that impair the immune system. Additionally, the disease itself, especially when active, can increase the risk of infection.

Findings That Do Not Increase Susceptibility to Infection:

Hematocrit (Hct) of 47%:
- Explanation: The Hct level is within the normal range of 37% to 52%. It measures the percentage of red blood cells in the blood. Since it's normal, it does not indicate an increased risk of infection.
Hemoglobin (Hgb) of 16 g/dL:
- Explanation: The Hgb level is also within the normal range of 12 to 18 g/dL. Hemoglobin is a protein in red blood cells that carries oxygen. This normal level does not suggest a higher risk of infection.
Potassium level of 3.6 mEq/L:
- Explanation: Potassium levels are within the normal range of 3.5 to 5.0 mEq/L. This electrolyte level is unrelated to infection risk in the context provided.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is scheduling a client for surgery.Which of the following actions should the nurse take to obtain precertification for the client to have surgery?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

Findings that Could Increase Susceptibility to Infection:

Findings That Do Not Increase Susceptibility to Infection:

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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?