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 D

Explanation

The correct answer is choiced. Location of blood pressure cuff.

Choice A rationale:The systolic blood pressure of 102 mm Hg is within a normal range and does not require clarification.

Choice B rationale:The position of the client, “sitting up in a chair,” is clearly documented and does not need further clarification.

Choice C rationale:The unit of measurement, “mm Hg,” is the standard unit for blood pressure and is correctly documented.

Choice D rationale:The location of the blood pressure cuff is not specified in the documentation. It is important to document whether the blood pressure was taken on the left or right arm, or another location, to ensure accuracy and consistency in future measurements.

A. Accountability. B. Confidence. C. Fairness. D. Advocacy.

Correct Answer is A

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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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?