A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Remove one restraint at a time.
Tie the restraints to the side rail,
Secure restraints with a square knot
Remove the restraints every 3 hr
The Correct Answer is A
When using restraints for the safety of the client and others, it is important to follow proper procedures to ensure the client's well-being and minimize the risk of injury. Removing one restraint at a time allows for better control and assessment of the client's behavior and response. It also helps maintain the client's safety by ensuring that at least one limb is restrained during the process.
Restraints should never be tied to the side rail as it can cause serious harm or injury to the client. Restraints should be attached to an immobilization device specifically designed for that purpose, such as a bed frame or a designated restraint chair.
Restraints should be secured with a quick-release mechanism, such as a buckle or Velcro, that allows for quick and easy removal in case of emergency or the need for rapid intervention. Tying restraints with a square knot can delay the removal process and may compromise the client's safety.
Restraints should only be used when necessary and as prescribed by the healthcare provider. The frequency and duration of restraint use should be based on the client's condition and the specific order from the healthcare provider. It is not appropriate to remove restraints based solely on a time schedule without considering the client's individual needs and safety. Regular assessments should be conducted to determine if continued use of restraints is required or if alternative interventions can be implemented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E,C,D,B,A
Explanation
To perform a physical assessment of a client's abdomen, the nurse should follow the following sequence:
1. Provide adequate lighting to inspect the abdomen.
2. Listen to the abdominal arteries using the bell of a stethoscope.
3. Percuss all four quadrants of the abdomen to measure sound quality.
4. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.
5. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.
Correct Answer is C
Explanation
The client needs assistance with morning ADLs, and an occupational therapist is an interprofessional team member who can assist with activities of daily living. Physical therapists focus more on mobility and range of motion exercises, registered dieticians focus on nutrition, and speech-language pathologists work with clients who have difficulty with speech and swallowing.
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