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 B
Explanation
Choice A rationale:
A pulse rating of 2+ is not considered an expected finding. It indicates a weaker pulse, which requires further assessment.
Choice B rationale:
A pulse rated as 2+ means the pulse is full volume and bounding. In clinical practice, a 2+ pulse is considered normal and signifies a pulse that is easily palpable and has a normal strength. This is an essential finding for the nurse to understand because it reflects the circulatory status of the client. A 2+ pulse suggests adequate perfusion and a healthy heart pumping blood effectively.
Choice C rationale:
A pulse rating of increased and strong corresponds to a higher numeric value on the scale, indicating a stronger pulse. A 2+ pulse is not categorized as increased but is rather a moderate strength pulse.
Choice D rationale:
A pulse rating of 2+ does not suggest an absent pulse. An absent pulse would mean that no pulse can be felt, which is a critical situation requiring immediate medical attention.
Correct Answer is D
Explanation
The correct answer is D. Determine the client's ability to help with the transfer.
Choice A rationale:
While obtaining a walker might be helpful, it's not the first step. The nurse needs to assess the client's ability to assist with the transfer before deciding on the most appropriate aid.
Choice B rationale:
Calling for additional staff may be necessary, but this should come after assessing the client's ability to help with the transfer.
Choice C rationale:
Using a transfer belt is a good practice for safe transfers, but again, the nurse must first determine if the client can assist. This ensures the appropriate use of resources and techniques.
Choice D rationale:
Assessing the client's ability to help with the transfer is the first step. This assessment will guide the nurse in choosing the safest and most appropriate method for transferring the client, considering their capabilities and safety.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.