A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly?
The restraints are attached to the side rails of the client's bed.
The nurse can insert three fingers under the secured restraint.
The restraints are secured with a quick-release knot.
The restraint's soft pad faces away from the client's skin.
The Correct Answer is C
The correct answer is choice c. The restraints are secured with a quick-release knot.
Choice A rationale:
The restraints should never be attached to the side rails of the bed. This can cause injury if the side rails are moved up or down. Instead, restraints should be attached to a part of the bed frame that does not move.
Choice B rationale:
The nurse should be able to insert only two fingers under the secured restraint. If three fingers can be inserted, the restraint is too loose and may not effectively prevent the patient from harming themselves or others.
Choice C rationale:
Securing the restraints with a quick-release knot is correct because it allows for easy and rapid removal in case of an emergency.
Choice D rationale:
The soft pad of the restraint should face the client’s skin to prevent skin irritation and injury. If the soft pad faces away from the skin, it can cause discomfort and potential harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When a client is receiving gentamicin via IV infusion, it's essential to monitor for potential adverse effects. One of the well-known adverse effects of gentamicin is ototoxicity, which can manifest as hearing loss. Therefore, the nurse should identify the following manifestation as an adverse effect of the treatment:
B) New onset of hearing loss
Hypotension (option A), hyperthermia (option C), and slurred speech (option D) are not typically associated with gentamicin use and would be less likely to be related to the treatment. However, it's essential to assess the client for other side effects and monitor their overall condition while receiving gentamicin to ensure their safety and well-being.
Correct Answer is C
Explanation
Explanation: According to the Institute of Medicine, women who are obese before pregnancy (BMI of 30 or higher) should gain 11 to 20 pounds during pregnancy. Therefore, 16 lb is an acceptable weight gain for this client.
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