A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

The client's hand is cool and pale

The client has full range of motion in her wrist

The client is attempting to remove the restraint.

The client has a capillary refill of less than 2 seconds.

Answer and Explanation

The Correct Answer is A

A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.

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Correct Answer is B

Explanation

A) Delayed gastric emptying: This condition refers to a slowdown in the movement of food from the stomach to the small intestine, often leading to symptoms like nausea, vomiting, bloating, and early satiety. It is not related to breath sounds and would not be detected through auscultation of the lungs.

B) Atelectasis: This condition involves the collapse or closure of lung tissue, resulting in reduced or absent gas exchange. It commonly occurs in patients who are immobile or on bedrest for extended periods, such as the client with a lacerated spleen. Decreased breath sounds in the lower lobes of the lungs are a typical finding in atelectasis, as the collapsed or partially collapsed alveoli do not allow air to move through them, leading to diminished or absent breath sounds in the affected areas.

C) An upper respiratory infection: This condition involves infections in the nose, throat, and airways and typically presents with symptoms like cough, nasal congestion, sore throat, and sometimes fever. It can affect breath sounds, but it more commonly causes wheezing, crackles, or rhonchi rather than isolated decreased breath sounds in the lower lobes.

D) Pulmonary edema: This condition is characterized by the accumulation of fluid in the lungs, often due to heart failure or acute lung injury. Auscultation findings typically include crackles or rales, particularly in the lower lung fields, but not necessarily decreased breath sounds unless there is a significant consolidation or fluid volume.

A. Lactated Ringer's B. Dextrose 10% in water C. 0.45% sodium chloride D. Dextrose 5% in 0.9% sodium chloride

Correct Answer is C

Explanation

A) Lactated Ringer's:
Lactated Ringer's solution is an isotonic crystalloid solution that contains electrolytes similar to those found in plasma. It is commonly used for fluid resuscitation and maintenance therapy but is not typically used for treating hypernatremia, as it contains sodium chloride and could exacerbate the client's condition.

B) Dextrose 10% in water:
Dextrose 10% in water is a hypertonic solution primarily used to provide calories and treat hypoglycemia. It does not address the underlying electrolyte imbalance in hypernatremia.

C) 0.45% sodium chloride:
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution used to treat hypernatremia by diluting the excess sodium in the bloodstream. It provides free water to rehydrate cells without adding excessive sodium. This solution is appropriate for clients with hypernatremia who require IV fluid therapy.

D) Dextrose 5% in 0.9% sodium chloride:
Dextrose 5% in 0.9% sodium chloride, also known as D5NS, is a hypertonic solution containing both dextrose and sodium chloride. While it provides water and calories, the sodium content may exacerbate hypernatremia rather than correct it. Therefore, it is not the most appropriate choice for a client with hypernatremia.

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A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

Correct Answer is C

Explanation

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