A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
Make sure four fingers fit between the restraint and the client's body.
Apply the belt restraint over the client's gown.
Check the client's skin integrity every 4 hr.
Tie the belt restraint to the side rail of the bed.
The Correct Answer is B
Rationale:
A. Ensuring that four fingers fit between the restraint and the client's body is important to prevent injury and discomfort.
B. Applying the belt restraint over the client's gown may lead to slippage and ineffective restraint.
C. Checking the client's skin integrity every 4 hours is important, but it is not specific to the use of a belt restraint.
D. Tying the belt restraint to the side rail of the bed is not appropriate because it can restrict movement and cause injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A fever may influence the result of an oxygen saturation test but is not a direct factor.
B. An elevated hemoglobin level is unlikely to influence the result of an oxygen saturation test.
C. Wearing a ring is unlikely to influence the result of an oxygen saturation test.
D. Wearing nail polish can interfere with the accuracy of pulse oximetry readings by causing an inaccurate reflection of light, leading to a falsely low oxygen saturation reading.
Correct Answer is D
Explanation
Rationale:
A. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
B. This response is judgmental and may not support the client's autonomy in making healthcare decisions.
C. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
D. This response acknowledges the client's decision and supports the client in discussing their decision with loved ones.
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