A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.
Which action is appropriate for the nurse to conduct for a patient in restraints?

Apply ankle restraints but leave the wrists unrestrained.

Tie a double knot that is difficult to undo.

Tie a slip knot to the side rails of the bed.

Check on the patient frequently.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Applying ankle restraints but leaving the wrists unrestrained is not a balanced approach. Restraints should only be used when necessary and should be applied correctly following the healthcare facility's policies and guidelines. Applying restraints to one part of the body while leaving another unrestrained can lead to injuries and is not a safe practice.

Choice B rationale:

Tying a double knot that is difficult to undo can be dangerous in emergency situations. Restraints should allow for quick release in case of emergencies, ensuring patient safety. Difficult-to-undo knots can delay the removal of restraints, leading to potential harm to the patient.

Choice C rationale:

Tying a slip knot to the side rails of the bed is unsafe and against restraint protocols. Slip knots can tighten when pulled, increasing the risk of injury to the patient. Restraints should be applied to designated areas and never tied to movable parts of the bed or other objects in the room.

Choice D rationale:

Checking on the patient frequently is the most appropriate action when a patient is in restraints. Regular monitoring ensures the patient's safety and well-being, assesses their comfort, and allows for prompt response to any signs of distress or discomfort. Frequent checks also help in preventing complications associated with immobilization, such as pressure ulcers and impaired circulation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice D rationale:

Adduction is the movement of a body part toward the midline of the body. When the nurse moves the patient's leg toward the midline of the patient's body, it is an adduction movement of the hip joint. This movement involves bringing the leg back to the body's midline, which is the opposite of abduction, where the leg moves away from the midline.

Choice A rationale:

Flexion refers to the bending of a joint, decreasing the angle between two body parts. This is not the correct term for moving the leg toward the midline; it describes a different movement.

Choice B rationale:

Abduction is the movement of a body part away from the midline of the body. It is the opposite movement to adduction. When the leg moves away from the midline, it is in abduction, not adduction.

Choice C rationale:

Extension refers to the straightening of a joint, increasing the angle between two body parts. It is the opposite movement to flexion. This movement does not involve bringing the leg toward the midline.

A. Call the physician to request an antianxiety medication. B. Share personal religious beliefs with the client. C. Sit quietly with the client and offer caring touch. D. Advise the client about a good worship center nearby.

Correct Answer is C

Explanation

Choice A rationale:

Calling the physician to request an antianxiety medication might address the client's anxiety, but it does not directly respond to the client's existential question about God punishing them.

Choice B rationale:

Sharing personal religious beliefs with the client can be inappropriate and may not align with the client's beliefs, potentially causing discomfort or offense.

Choice C rationale:

Sitting quietly with the client and offering caring touch demonstrates empathy, compassion, and presence. It allows the nurse to provide emotional support without imposing personal beliefs or judgments. This approach encourages the client to express their feelings and facilitates a therapeutic nurse-client relationship.

Choice D rationale:

Advising the client about a good worship center nearby does not directly address the client's existential question or provide emotional support. Additionally, the client may not be interested in religious activities at this moment.

View Question and Answer

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

A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.Which action is appropriate for the nurse to conduct for a patient in restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse performs range of motion by moving the patient's leg toward the midline of the patient's body.This movement would be documented as what of the hip?

Correct Answer is D

Explanation

The nurse is caring for a client who is in the final stages of cancer, is depressed and distant.The client asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

Correct Answer is C

Explanation

The student nurse is reviewing topics related to laws that apply to nursing care.The student nurse is correct in stating which one is the nurse's best defense if a patient alleges nursing negligence?

The nurse has an order for 27 mg of Augmentin three times daily for a 6-year-old. The pharmacy sends a vial labeled 20 mg/1 mL when reconstituted with 2.3 mL of saline. How many mL will the nurse administer per day?

A nursing student uses an uncommon and unrecognized abbreviation when charting on a patient.While re-educating the student nurse, what reasoning should the nurse provide for not using uncommon and unrecognized abbreviations?

A nurse uses the SBAR method to give report about a patient to another unit in the hospital.What statement by the nurse would the nurse identify as the "situation" portion of the SBAR report?

A nurse is caring for a terminally ill patient with questions regarding end-of-life care options.The nurse provides an informational packet to the patient, and discusses the various care options available.The nurse is demonstrating which professional value?

The director of nursing reprimands the nursing staff for which violations of HIPAA policy? Select all that apply.

What is the nursing priority when logrolling a patient?

A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.
Which action is appropriate for the nurse to conduct for a patient in restraints?