A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot.
Which of the following actions should the nurse take?
Retie the restraint straps with a slipknot.
Check that three fingers will fit beneath the restraints.
Retie the restraint straps to the side rails.
Remove the padding under the wrist restraints.
The Correct Answer is A
The correct answer is choice a. Retie the restraint straps with a slipknot.
Choice A rationale:
The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.
Choice B rationale:
It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.
Choice C rationale:
Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.
Choice D rationale:
The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
When preparing to open a sterile pack, the nurse must touch only the inner surface of the inner wrapper to maintain sterility. This is a fundamental principle of aseptic technique. Sterile items should be handled with care to prevent contamination. By touching only the inner surface of the inner wrapper, the nurse ensures that the contents of the pack remain sterile and safe for use in medical procedures. Any contact with the outer surface or other non-sterile items can compromise the sterility of the contents.
Choice A rationale:
Placing the sterile pack on a clean surface is a good practice but does not ensure the maintenance of sterility. Sterile items should be placed on a sterile surface or field to prevent contamination. Placing the pack on a clean surface may still expose it to potential contaminants, compromising its sterility.
Choice B rationale:
Turning the pack so that the first flap faces the nurse's body is incorrect. The first flap should be opened away from the nurse to avoid the risk of contamination. By opening the flap away from the nurse, any potential contaminants in the air are less likely to come into contact with the sterile contents.
Choice C rationale:
Opening the right-side flap first is not a standard practice for opening a sterile pack. The choice of which side to open first may vary based on individual preference or the design of the packaging. The key factor is to maintain the sterility of the contents by handling the pack appropriately, as mentioned in choice D.
Correct Answer is D
Explanation
Choice A rationale:
Wearing a mask when entering the client's room is not specifically required for contact precautions. Masks are primarily used for airborne precautions or when caring for patients with respiratory infections spread through droplets.
Choice B rationale:
Removing potted plants from the room may be a good practice for infection control, but it is not a specific action mandated by contact precautions. Contact precautions primarily focus on preventing the transmission of infections through direct or indirect contact with the patient or their environment.
Choice C rationale:
Allowing the client to leave the room every 2 hours is not a recommended practice for contact precautions. Patients under contact precautions should ideally stay in their rooms to prevent the spread of infections to others in the healthcare facility.
Choice D rationale:
When caring for a client under contact precautions, it is essential to dedicate equipment and supplies for their use exclusively. This helps prevent the spread of infections to other patients or healthcare workers by avoiding the contamination of shared items.
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