A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?
The restraint tie strap is tied into a knot.
The restraint is attached to the side rails of the bed.
The skin under the restraint is cool and has changed color.
The nurse can insert two fingers under the restraint.
The Correct Answer is D
Rationale:
A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.
B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.
C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.
D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "I should use a firm mattress in my baby's crib.": A firm mattress reduces the risk of sudden infant death syndrome (SIDS) and suffocation by providing a stable, flat surface for safe infant sleep. This is a key recommendation in safe sleep guidelines.
B. "I should set my hot water heater at 130 degrees Fahrenheit.": Setting the water heater at 130°F increases the risk of scald burns, especially for infants and young children. The recommended temperature to prevent burns is 120°F or lower.
C. “I should use a crib with side rails that drop": Drop-side cribs have been banned due to safety concerns, including risk of entrapment and suffocation. Using a crib with fixed side rails is safer and recommended.
D. "I should position my baby on their stomach to sleep during the day.": Placing infants on their stomach to sleep increases the risk of SIDS. The safest position for sleep is on the back, both during the day and night.
Correct Answer is D
Explanation
Rationale:
A. Measles, mumps, and rubella (MMR): MMR is a live attenuated vaccine and is contraindicated during pregnancy due to the risk of fetal harm. It should be given at least one month prior to conception or postpartum if immunity is needed.
B. Varicella (VAR): Like MMR, the varicella vaccine is live and should not be administered during pregnancy. Pregnant individuals without evidence of immunity should receive it postpartum to protect against future infections.
C. Tetanus diphtheria and pertussis (Tdap): Tdap is recommended during each pregnancy but typically between 27 and 36 weeks of gestation to maximize passive antibody transfer to the fetus. At 16 weeks, it would not yet be indicated.
D. Inactivated influenza (IV): The inactivated flu vaccine is recommended for all pregnant clients during flu season, regardless of the trimester. It protects both the pregnant individual and the fetus from complications related to influenza infection.
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