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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Psychologist: A psychologist focuses on mental health assessment and therapy rather than medication management. While they are essential for emotional and psychological support, they are not trained to evaluate or address potential drug interactions in a client's medication regimen.

B. Advanced practice nurse: An advanced practice nurse, such as a nurse practitioner, has the education and authority to assess medication regimens, recognize potential drug interactions, and make adjustments or recommendations. They are well-qualified to manage complex medication issues and collaborate closely with prescribing providers.

C. Patient care technician: Patient care technicians assist with basic care activities such as hygiene, mobility, and vital signs monitoring but do not have the education or licensure required to evaluate medications. They are not involved in clinical decision-making regarding pharmacologic therapy.

D. Social worker: A social worker provides resources for social support, financial assistance, and counseling, but medication management is outside their scope of practice. They are valuable for holistic care but not for assessing or managing drug interactions specifically.

A. Explain the rounding schedule to the client B. Tell the client about the visiting hours C. Review meal options with the client. D. Place the call light within reach of the client.

Correct Answer is D

Explanation

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

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Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

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?

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