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.

Answer and Explanation

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.

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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.

A. Rinsing gloves that become visibly soiled during use. B. Using antimicrobial soap for routine handwashing. C. Disinfecting hands immediately after removing gloves. D. Keeping gloves on when touching environmental surfaces.

Correct Answer is C

Explanation

Choice A rationale:

Scabies is a skin infestation caused by the Sarcoptes scabiei mite. While it is contagious, it does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves, are sufficient when caring for a client with scabies.

Choice B rationale:

Mycoplasmal pneumonia is a type of pneumonia caused by the bacteria Mycoplasma pneumoniae. It is typically spread through respiratory droplets and does not require the use of an N95 respirator mask. Standard precautions, including wearing a mask, are appropriate for this condition.

Choice C rationale:

Tuberculosis (TB) is a highly contagious bacterial infection caused by Mycobacterium tuberculosis. TB spreads through the air when an infected person coughs or sneezes. To prevent the inhalation of TB bacteria, healthcare workers should wear N95 respirator masks (or higher level respirators) when caring for clients with active TB disease.

Choice D rationale:

Scarlet fever is a bacterial illness that develops in some people who have strep throat. It is caused by group A Streptococcus bacteria and is typically treated with antibiotics. Scarlet fever does not require the use of an N95 respirator mask. Standard precautions, including wearing gloves and a mask, are appropriate when caring for a client with scarlet fever. Wearing an N95 respirator mask is crucial when caring for clients with airborne infectious diseases like tuberculosis. This type of mask is designed to filter out at least 95% of airborne particles, providing a high level of protection for healthcare workers.

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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?

Nursing Test Bank

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A nurse notes a client's pulse is a 2+ and understands this means what about the pulse?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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?