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 ["A","B","C","E"]
Explanation
Choice A rationale:
Family members who smoke must be at least 10 ft from the client when oxygen is in use. Oxygen supports combustion, and smoking near an oxygen source can lead to a fire. Keeping family members who smoke at a safe distance minimizes this risk.
Choice B rationale:
Nail polish remover or hair spray should not be used near a client who is receiving oxygen. These substances contain flammable ingredients, which can ignite in the presence of oxygen. Instructing the client and those around them to avoid using such products prevents potential accidents.
Choice C rationale:
A "No Smoking" sign should be placed on the front door. This serves as a visual reminder to visitors and family members that smoking is prohibited in the vicinity, reducing the risk of fire when oxygen is in use. Clear communication through signage is essential in maintaining a safe environment.
Choice E rationale:
A fire extinguisher should be readily available in the home. Despite precautions, accidents can still happen. Having a fire extinguisher nearby allows for immediate response in case of a fire-related emergency, ensuring the safety of the client and those around them.
Choice D rationale:
Cotton bedding and clothing should be replaced with items made from wool. This statement is incorrect. There is no specific requirement to replace cotton items with wool for a client using oxygen. Instead, the focus should be on fire safety measures and ensuring that flammable materials are kept away from the oxygen source.
Correct Answer is B
Explanation
Choice A rationale:
Gastro- refers to the stomach. This prefix is commonly used in medical terminology to indicate conditions related to the stomach or the gastrointestinal system.
Choice B rationale:
Nephro- is the correct medical term for kidney. The prefix nephro- is used to indicate conditions related to the kidney, such as nephritis (inflammation of the kidney)
Choice C rationale:
Oto- refers to the ear. This prefix is commonly used in medical terms related to the ear and hearing, such as otitis (inflammation of the ear)
Choice D rationale:
Uro- refers to the urinary tract. While it is related to the kidneys in the context of the urinary system, it is not the specific term for kidney. Uro- is used in words like urology (the branch of medicine that deals with the urinary system and male reproductive system)
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