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 is attached to the side rails of the bed.
The restraint the strap is tied into a knot.
The nurse can insert two fingers under the restraint.
The skin under the restraint is cool and has changed color.
The Correct Answer is C
A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.
B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.
C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.
D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased senses: PCA pump use, typically involving opioids, does not heighten the senses. Instead, opioids often dull sensory perception and can cause sedation rather than making sensations sharper or more intense.
B. Decreased sleep: Opioids used in PCA pumps often promote drowsiness and sleep rather than reducing it. Sleep disturbances are not a common direct effect of properly managed PCA analgesia unless pain remains uncontrolled.
C. Difficulty swallowing: Difficulty swallowing is not a usual side effect associated with PCA use. If it occurs, it would likely suggest another issue, such as a neurological problem, rather than a typical reaction to PCA-administered opioids.
D. Urinary frequency: Opioids can affect the bladder by either causing urinary retention or, less commonly, altering normal patterns. Clients receiving adequate hydration and pain management might experience urinary frequency, especially as mobility increases postoperatively.
Correct Answer is B
Explanation
A. "Let's review hormonal contraceptives first": Redirecting the conversation to hormonal contraceptives ignores the client’s expressed preference. Effective communication involves respecting client choices and supporting informed decision-making rather than pushing alternative methods first.
B. "I will provide you with more information about this": This response supports the client’s autonomy by offering information tailored to their expressed interest. Providing education about natural family planning, including techniques and effectiveness, allows the client to make an informed and empowered decision.
C. "Have you considered other alternatives": While exploring options is sometimes appropriate, immediately questioning the client's choice may feel dismissive. It is important to first respect and address the client's initial interest before introducing other possibilities if needed.
D. "Natural family planning is not beneficial for everyone.": Although this statement may be true in some cases, it is not an appropriate initial response. It risks discouraging the client prematurely rather than fostering an open, supportive discussion about how to use natural family planning effectively.
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