A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot.
What action should the nurse take?

Check that three fingers will fit beneath the restraints.

Retie the restraint straps with a slipknot.

Retie the restraint straps to the side rails.

Remove the padding under the wrist restraints.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While it is important to ensure that restraints are not too tight, the issue in this scenario is not related to the tightness of the restraints.
Choice B rationale
Restraints should be tied with a slipknot to allow for quick release if necessary. A double knot may be difficult to untie quickly in an emergency.
Choice C rationale
Restraint straps should not be tied to the side rails. If the side rails are lowered, the restraints could become too loose.
Choice D rationale
The padding under the wrist restraints should not be removed. The padding helps to prevent skin damage and increase the comfort of the patient.

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Correct Answer is B

Explanation

Choice A rationale

Full-thickness tissue loss extending to underlying support structures such as muscle, tendon, or bone is characteristic of a stage 4 pressure ulcer, not a stage 312.
Choice B rationale
A stage 3 pressure ulcer involves full-thickness skin loss and may appear as a deep crater. There may be damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This description matches the statement in Choice B, making it the correct answer.
Choice C rationale
A shallow, ruptured or intact skin blister without slough is more indicative of a stage 2 pressure ulcer. In a stage 2 pressure ulcer, there is partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.
Choice D rationale
Unbroken skin with un-blancheable erythema is characteristic of a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin is not broken, but it has redness that does not lighten (or blanch) when you press on it.

A. Vibration B. Percussion C. Postural drainage D. Nebulization

Correct Answer is A

Explanation

Choice A rationale
Vibration is a technique used in chest physiotherapy to increase the turbulence of the client’s exhaled air. It involves the use of manual or mechanical techniques to create vibrations in the chest wall during exhalation. This helps to loosen mucus in the airways and improve clearance of secretions.
Choice B rationale
Percussion, also known as chest clapping, is a technique used in chest physiotherapy to help loosen and mobilize secretions in the lungs. However, it does not specifically increase the turbulence of exhaled air.
Choice C rationale
Postural drainage involves positioning the client in specific ways to use gravity to assist in the removal of secretions from the lungs. While it can be beneficial in managing respiratory infections, it does not directly increase the turbulence of exhaled air.
Choice D rationale

Nebulization involves the use of a machine to create a mist of medication that the client inhales into the lungs. While it can be used to deliver medications to help manage respiratory infections, it does not increase the turbulence of exhaled air.

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A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which statement should the nurse use to describe a stage 3 pressure ulcer?

Correct Answer is B

Explanation

A nurse is performing chest physiotherapy on a client with a respiratory infection. Which technique should the nurse use to increase the velocity and turbulence of the client’s exhaled air?

Correct Answer is A

Explanation

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A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot.
What action should the nurse take?