A nurse is caring for a client who has become aggressive and requires the placement of wrist restraints to maintain the client's safety. Which of the following actions should the nurse take?

Observe the circulation of the client's extremities.

Use square knots to secure the client's restraint.

Tie the restraint to the rail of the client's bed.

Obtain the client's vital signs every 4 hr.

Answer and Explanation

The Correct Answer is A

A. Observe the circulation of the client's extremities: Regularly assessing the neurovascular status of restrained extremities is critical to ensure that the restraints are not compromising blood flow or causing tissue injury. The nurse should check for color, temperature, pulse, capillary refill, and sensation frequently to maintain client safety.

B. Use square knots to secure the client's restraint: Restraints should be secured using quick-release knots rather than square knots, allowing the nurse to remove them quickly in an emergency. Square knots are difficult to untie and can delay rapid intervention if complications arise.

C. Tie the restraint to the rail of the client's bed: Restraints should never be tied to moveable parts of the bed, such as rails, because this can cause injury if the bed is adjusted. Restraints should be secured to a stationary part of the bed frame to prevent entanglement or injury.

D. Obtain the client's vital signs every 4 hr: When a client is restrained, vital signs should be monitored more frequently than every 4 hours, typically every 15–30 minutes initially, to detect changes in condition or signs of distress. Less frequent monitoring does not ensure early identification of complications.

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Correct Answer is C

Explanation

A. Temperature 36.7° C (98° F): This temperature is within normal limits for an adult and does not indicate a complication related to imipramine use. No immediate intervention is needed based on this finding.

B. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within the normal adult range (12–20/min) and does not raise concern for adverse effects from imipramine. It requires routine monitoring only.

C. Blood pressure 88/64 mm Hg: Imipramine, a tricyclic antidepressant, can cause orthostatic hypotension and other hypotensive effects. A blood pressure of 88/64 mm Hg is lower than normal and may indicate drug-induced hypotension, which requires follow-up, monitoring for symptoms such as dizziness or syncope, and possibly notifying the prescriber.

D. Pulse rate 66/min: A pulse rate of 66 beats per minute is within the normal adult range (60–100 bpm) and does not indicate a cardiovascular complication related to imipramine. Routine monitoring is sufficient.

A. Documents the client's refusal of their prescribed medications. B. Provides a quiet space for the client if they become agitated C. Informs the client about the adverse effects of their medication D. Returns at the promised time to sit and talk with the client

Correct Answer is D

Explanation

A. Documents the client's refusal of their prescribed medications: Accurate documentation reflects professional responsibility and legal accountability, but it is related to veracity and accountability rather than fidelity, which focuses on keeping commitments.

B. Provides a quiet space for the client if they become agitated: Creating a safe environment demonstrates beneficence and respect for the client’s well-being, but it does not specifically reflect fidelity, which emphasizes faithfulness and honoring promises.

C. Informs the client about the adverse effects of their medication: Educating the client supports informed consent and autonomy, aligning with the principle of veracity, but it does not directly involve keeping a commitment or promise.

D. Returns at the promised time to sit and talk with the client: Returning at the promised time demonstrates fidelity by maintaining trust and keeping commitments made to the client. This action strengthens the therapeutic relationship and models reliability and consistency in care.

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A nurse is caring for a client who has become aggressive and requires the placement of wrist restraints to maintain the client's safety. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the vital signs of a client who has a prescription for imipramine. Which of the following findings requires follow-up by the nurse?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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