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 A
Explanation
Choice A rationale:
In this scenario, the nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). By collecting evidence-based information and research on this topic, the nurse is acting in the role of a researcher. Research in healthcare is essential to stay current with best practices, guidelines, and recommendations, and it helps inform clinical decision-making.
Choice B rationale:
A nurse manager is responsible for overseeing nursing staff, unit operations, and ensuring that the unit operates efficiently and safely. While a nurse manager may use evidence-based information to guide decisions, the primary role described in this scenario is that of a researcher, as the nurse is focused on gathering evidence-based practice on a specific topic.
Choice C rationale:
An educator's primary role is to teach and educate others, such as patients, families, or fellow healthcare professionals. While education often involves the use of evidence-based information, in this scenario, the nurse is primarily focused on gathering evidence rather than directly educating others.
Choice D rationale:
A case manager is responsible for coordinating and managing a patient's care, often involving multiple aspects of healthcare and social services. While case managers may use evidence-based information in their decision-making, the primary role described in this scenario is that of a researcher, as the nurse is focused on gathering evidence-based practice related to CAUTI, not managing a specific patient's case.
Correct Answer is D
Explanation
The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.
Choice A rationale:
Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).
Choice B rationale:
Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.
Choice C rationale:
Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.
Choice D rationale:
Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.
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