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. Using the incentive spirometer is important for preventing atelectasis, but it does not prevent orthostatic hypotension.
B. Dangling the legs over the side of the bed before standing helps reduce the risk of orthostatic hypotension by allowing the body to gradually adjust to the change in position.
C. Increasing protein intake is important for wound healing and tissue repair, but it does not prevent orthostatic hypotension.
D. Performing regular isometric exercises is important for maintaining muscle strength and mobility, but it does not prevent orthostatic hypotension.
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.
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