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. Fats: While fats provide energy and help with cell membrane structure, they are not the primary nutrient required to promote wound healing. Excess fat intake without proper balance may not directly aid in faster tissue repair.
B. Calcium: Calcium is important for bone health and muscle function but does not play a central role in soft tissue wound healing. It is more critical in fracture healing rather than open wound repair.
C. Vitamin D: Vitamin D supports calcium absorption and bone health. Although it contributes to immune function, it is not the main nutrient needed to directly repair skin and soft tissue wounds.
D. Protein: Protein is essential for wound healing because it supports cell growth, tissue repair, and immune function. Adequate protein intake is critical to form new tissue, promote collagen synthesis, and restore skin integrity in clients with open wounds.
Correct Answer is ["A","C"]
Explanation
A. Review the need for the indwelling urinary catheter daily: Daily review of catheter necessity reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal when no longer needed limits bacterial entry and colonization, which significantly lowers infection rates in hospitalized clients.
B. Empty the drainage bag when it is half full: The drainage bag should be emptied when it is about two-thirds full, not half full, to prevent backflow and reduce strain on the system. Emptying too early or too often increases the risk of introducing pathogens into the closed system.
C. Use soap and water to provide perineal care: Using soap and water for perineal hygiene maintains cleanliness and reduces bacterial colonization near the catheter site. Routine perineal care is a critical intervention to minimize the risk of ascending infections into the urinary tract.
D. Place the drainage bag on the bed when transporting the client: The drainage bag must remain below bladder level during transport to prevent backflow of urine into the bladder. Placing the bag on the bed risks contamination and promotes reflux of potentially infected urine.
E. Encourage the client to drink 1000 mL of fluid daily: Although hydration generally helps prevent UTIs, this client is on a strict 1000 mL fluid restriction due to heart failure. Encouraging more fluid intake could worsen fluid overload and does not align with current prescribed therapy.
F. Change the indwelling urinary catheter tubing every 3 days: Routine changing of catheter tubing is not recommended unless clinically indicated (e.g., contamination, obstruction, infection). Unnecessary manipulation increases the risk of introducing pathogens into the urinary system.
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