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
The correct answer is Choice A: Coordinates all healthcare client has received into one platform.
Choice A rationale:
Electronic health records (EHRs) integrate all of a patient's healthcare information into one centralized platform, making it easier for healthcare providers to access and coordinate care.
Choice B rationale:
While EHRs can allow for sharing information with authorized individuals, granting significant other access to client information is not a primary function of EHRs and requires specific consent and permissions.
Choice C rationale:
EHRs do provide information that can be used for research studies, but this is not a primary benefit emphasized in patient education.
Choice D rationale:
EHRs do allow clients to access their medical records electronically, but this is not the primary focus of the teaching about the benefits of EHRs.
Correct Answer is B
Explanation
Choice A rationale:
Assessment Assessment is the first step of the nursing process, where the nurse collects data about the patient's condition. While this step is crucial for understanding the patient's needs, it does not involve formulating goals for a positive outcome. Therefore, it is not the correct choice in this context.
Choice B rationale:
Planning Planning is the step of the nursing process where the nurse formulates goals and develops a care plan to achieve those goals. This includes setting objectives for the patient's care and determining the best course of action. In this case, the nurse is formulating goals for a positive outcome, making choice B the correct answer.
Choice C rationale:
Evaluation Evaluation is the step where the nurse assesses the patient's response to the care provided and determines whether the goals have been met. While important, it does not involve the initial formulation of goals, so it is not the correct choice for this question.
Choice D rationale:
Implementation Implementation involves carrying out the plan of care, putting the planned interventions into action. It doesn't focus on goal formulation, so it is not the correct answer in this context.
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