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. A stoma that protrudes slightly from the abdomen is normal after colostomy surgery.
B. A stoma that appears dark in color may indicate compromised blood flow and should be reported to the provider.
C. A stoma that bleeds lightly when touched is normal after colostomy surgery.
D. A stoma that is draining a small amount of liquid stool is normal after colostomy surgery.
Correct Answer is D
Explanation
Rationale:
A. Small, raised vesicles over the body may indicate an allergic reaction but are not typically associated with IV antibiotics.
B. Rhinitis may indicate an allergic reaction but is not typically associated with IV antibiotics.
C. Itching of the skin may indicate an allergic reaction but is not typically associated with IV antibiotics.
D. Severe wheezing may indicate an allergic reaction or anaphylaxis and should be reported immediately.
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