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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I will use animal skin condoms when having sex.": Animal skin condoms do not provide reliable protection against HIV transmission because they have small pores that can allow viruses to pass through. Latex or synthetic condoms are recommended for effective protection.

B. "I will put soiled dressings in a tied plastic bag before placing them in the trash.": Properly disposing of soiled dressings in a securely tied plastic bag helps prevent the spread of infectious material and minimizes the risk of exposure to others, reflecting good infection control practices at home.

C. "I will place used sharp items in an empty cereal box for disposal.": Sharps should be disposed of in a puncture-resistant, labeled sharps container. An empty cereal box is not puncture-proof and can easily be breached, posing a significant risk for needlestick injuries.

D. "I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water.": The correct disinfection solution for HIV is a mixture of one part bleach to 10 parts water, not peroxide. Using an incorrect disinfectant reduces the effectiveness of killing the virus on surfaces.

A. "Advance directives are the same as a consent form for health care treatment” B. "Advance directives are for clients who have life-threatening conditions." C. "Advance directives must be approved by your lawyer.” D. "Advance directives protect your right to make your own health care decisions.”

Correct Answer is D

Explanation

A. "Advance directives are the same as a consent form for health care treatment": Advance directives are different from a consent form. A consent form is specific to the current treatment or procedure, while advance directives outline future healthcare wishes in the event the client becomes unable to make decisions.

B. "Advance directives are for clients who have life-threatening conditions.": While advance directives are especially important for clients with serious illnesses, they are appropriate for all adults, regardless of current health status, to ensure their wishes are known and respected if they become incapacitated.

C. "Advance directives must be approved by your lawyer.": Advance directives do not require a lawyer's approval to be valid. They usually need to be signed by the client and witnessed or notarized, depending on state laws, but legal counsel is not mandatory for completing one.

D. "Advance directives protect your right to make your own health care decisions.": Advance directives ensure that a client’s wishes regarding healthcare are known and respected even if they cannot voice them later. They preserve the client’s autonomy and legal rights concerning treatment preferences.

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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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