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
The correct answer is Choice D. Speak with the AP before leaving the shift about the appropriate protocol.
Choice A rationale: Giving the AP the appropriate PPE is not the best action for the nurse to take. While this might prevent the AP from spreading the infection to other clients or themselves, it does not address the root cause of the problem, which is the AP’s lack of knowledge or compliance with the infection control policies. The nurse should educate the AP about the importance of wearing PPE and the consequences of not doing so. Giving the AP the appropriate PPE might also imply that the nurse condones the AP’s behavior, which could undermine the nurse’s authority and credibility.
Choice B rationale: Notifying the charge nurse about the AP’s lack of PPE is not the best action for the nurse to take. While this might alert the charge nurse to the issue and prompt corrective action, it does not demonstrate the nurse’s leadership and communication skills. The nurse should first attempt to resolve the issue directly with the AP, as this shows respect and professionalism. Notifying the charge nurse might also create a sense of distrust and resentment between the nurse and the AP, which could affect their working relationship and teamwork.
Choice C rationale: Volunteering to provide an in-service about infection control is not the best action for the nurse to take. While this might be a helpful and proactive way to educate the staff about the infection control policies and procedures, it does not address the immediate issue of the AP’s lack of PPE. The nurse should first speak with the AP and ensure that they understand and follow the contact precautions for the client. Volunteering to provide an in-service might also be seen as overstepping the nurse’s role and scope of practice, as this is usually the responsibility of the infection control nurse or the staff development coordinator.
Choice D rationale: Speaking with the AP before leaving the shift about the appropriate protocol is the best action for the nurse to take. This shows that the nurse is concerned about the AP’s safety and the client’s well-being, as well as the infection control standards. The nurse should explain to the AP why they need to wear PPE when entering the room of a client who is under contact precautions, and what are the risks of not doing so. The nurse should also provide the AP with feedback and reinforcement, and document the incident and the intervention. Speaking with the AP before leaving the shift also ensures that the issue is addressed in a timely and respectful manner, and that the nurse and the AP have a clear and consistent understanding of the expectations and the outcomes.
Correct Answer is C
Explanation
Choice A rationale:
Modified equivalents. This is not the correct answer. The abbreviation "mEq" stands for milliequivalents, not modified equivalents.
Choice B rationale:
Megaequivalents. This is not the correct answer. "Mega" is a prefix indicating a factor of one million. In the context of electrolytes and medications, milliequivalents (mEq) are the appropriate unit of measurement, not megaequivalents.
Choice C rationale:
Milliequivalents. This is the correct answer. Milliequivalents (mEq) are a measure of the chemical combining power of a substance. In medical contexts, mEq is often used to express the amount of electrolytes (such as potassium, sodium, calcium) in a solution or dosage form. It represents 1/1000th of an equivalent, which is the amount of a substance that can react with or replace one mole of hydrogen ions (H+) It is important for healthcare professionals to understand these units when dealing with medications and intravenous fluids, as incorrect administration can lead to serious health complications.
Choice D rationale:
Miniequivalents. This is not the correct answer. "Mini" is not a standard prefix used in the International System of Units (SI) The correct prefix for a thousandth of an equivalent is "milli," making milliequivalents the appropriate unit of measurement for substances like electrolytes.
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