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 A
Explanation
Rationale:
A. Documenting the status of the episiotomy, including its size and approximation, is important for monitoring wound healing and ensuring appropriate postpartum care.
B. While providing self-care instructions is important, it is not a specific documentation related to the postpartum condition.
C. Fluid intake with meals is important for overall health but may not be specifically related to the postpartum condition.
D. Documenting an elevated oral temperature may be relevant for assessing the client's health status but is not specific to the postpartum condition.
Correct Answer is C
Explanation
Rationale:
A. Telling the client that it is safe to touch her ostomy may not address the client's concerns or fears.
B. Requesting that someone from the client's family participate in the care may not address the client's concerns or fears.
C. Asking the client to explain her feelings allows the nurse to understand the client's concerns or fears and address them appropriately.
D. Explaining why her participation is important may not address the client's concerns or fears.
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