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 C
Explanation
A. "If I decide to get implants in my arm, I will get them replaced every 10 years.": Contraceptive implants, such as etonogestrel (Nexplanon), typically last about 3 to 5 years, not 10 years. Misunderstanding the replacement timeline could leave a client unprotected against pregnancy if not corrected.
B. "If I decide to get pregnant again, tubal reconstruction is a reliable option.": Tubal ligation is considered a permanent form of contraception. Although tubal reversal surgery exists, it is not always successful and is not a reliable or guaranteed method for restoring fertility.
C. "I get the birth control injection, I will need an injection 4 times a year.": The birth control injection, such as depot medroxyprogesterone acetate (Depo-Provera), is administered every 3 months, which totals about 4 injections per year. This statement shows a correct understanding of the injection schedule.
D. "If I get an IUD placed, I will not have menstrual bleeding.": Some types of IUDs, particularly hormonal IUDs, may reduce menstrual bleeding significantly, but complete absence of bleeding does not occur in all clients. Copper IUDs, in contrast, may actually increase menstrual bleeding and cramping.
Correct Answer is D
Explanation
A. "I will take my inhaler treatment before each meal and at bedtime.": Budesonide is a corticosteroid used for long-term control of asthma, not for timing around meals. It is usually taken at set times daily to maintain airway inflammation control, not specifically related to mealtimes or bedtime alone.
B. "I should use my inhaler before exercising.": Using an inhaler before exercise is a strategy typically applied to short-acting bronchodilators like albuterol to prevent exercise-induced bronchospasm. Budesonide is a maintenance medication and is not intended for pre-exercise use.
C. "I should use my inhaler when I have an asthma attack.": Budesonide is not a rescue inhaler and should not be used during an acute asthma attack. Quick-relief inhalers like albuterol are used for immediate symptom management during asthma exacerbations.
D. "I will rinse my mouth and gargle with water after each inhaler treatment.": Rinsing the mouth after using an inhaled corticosteroid like budesonide is important to prevent oral thrush (candidiasis). This action demonstrates correct understanding of medication use and necessary precautions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.