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 B
Explanation
Rationale:
A. Creating advance directives to donate organs is not a primary purpose of advance directives.
B. Naming a sibling as a designee in a durable power of attorney for health care is a valid choice for appointing a healthcare proxy.
C. Advance directives do not require approval from an attorney.
D. A family member does not need to witness the client's signature on a living will.
Correct Answer is C
Explanation
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
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