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:

Ensuring that the television is on is not a recommended action when providing discharge teaching for an adolescent with a cognitive disorder and their parents. Television noise can be distracting and may hinder effective communication. The focus should be on clear, concise, and tailored communication to address the patient's and family's needs.

Choice B rationale:

Using short directive statements is a suitable approach when teaching a patient with a cognitive disorder and their parents. Patients with cognitive disorders may have difficulty processing complex information, so using concise and straightforward language can enhance understanding. It is essential to adapt teaching strategies to the individual's needs and abilities.

Choice C rationale:

Including medical slang in the teaching is not appropriate, as it can confuse and alienate patients and their families. The goal of discharge teaching is to ensure that the information provided is clear, easily understood, and accessible to the patient and their family. Using medical jargon or slang may hinder this objective.

Choice D rationale:

Including abstract imagery is not recommended when teaching a patient with a cognitive disorder. Abstract imagery can be challenging to understand, especially for individuals with cognitive impairments. Teaching materials should be concrete, straightforward, and tailored to the patient's cognitive abilities and comprehension levels.

A. "Collective bargaining is a competency that facilitates participation with other team members.”. B. "Confrontation is a competency that encourages interaction with other team members.”. C. "Communication with other team members is a competency that promotes openness in client care.”. D. "Coercive power over other team members is a competency that improves client outcomes.”. .

Correct Answer is C

Explanation

Choice A rationale:

Collective bargaining is not a competency related to interprofessional collaboration. It pertains more to labor relations and negotiations with employee unions.

Choice B rationale:

Confrontation is generally not a positive competency in the context of interprofessional collaboration. It can lead to conflicts and hinder teamwork.

Choice D rationale:

Coercive power over other team members is not a competency that promotes collaboration. Collaboration should be based on mutual respect and communication rather than coercion. Interprofessional collaboration involves effective communication, teamwork, and a shared understanding of patient care goals. Therefore, choice C, which emphasizes the importance of communication in promoting openness in client care, is the most appropriate answer.

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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 preparing to provide discharge teaching for an adolescent who has a cognitive disorder and their parents.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A charge nurse is providing teaching to a nursing team member about the competencies required for interprofessional collaboration.Which of the following statements by the nursing team member indicates an understanding?

Correct Answer is C

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?