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 ["4"]
Explanation
To calculate the correct dose in milliliters (mL), you can use the formula: Desired Dose (in mg) = Available Dose (in mg/mL) * Volume (in mL)
Desired Dose (in mg) = 40 mg Available Dose (in mg/mL) = 10 mg/1 mL Now, plug these values into the formula: Volume (in mL) = 40 mg / 10 mg/1 mL Volume (in mL) = 4 mL.
The nurse should administer 4 mL of furosemide per dose.
Correct Answer is C
Explanation
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