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 C
Explanation
The correct answer is choice C. Providing discharge teaching about home IV medication therapy.
Choice A rationale:
Administering a subcutaneous insulin injection is a task that can be delegated to a licensed practical nurse (LPN) or a trained unlicensed assistive personnel (UAP) under the supervision of an RN, as it is a routine and straightforward procedure.
Choice B rationale:
Collecting a sputum culture is also a task that can be performed by an LPN or a trained UAP. It does not require the advanced assessment skills of an RN.
Choice C rationale:
Providing discharge teaching about home IV medication therapy requires the advanced knowledge and skills of an RN. This task involves comprehensive education, assessment of the patient’s understanding, and ensuring the patient can safely manage their IV medication at home. It is critical for patient safety and effective care management.
Choice D rationale:
Removing an NG tube is a procedure that can be performed by an LPN or a trained UAP. It is a relatively simple task that does not require the advanced skills of an RN.
Correct Answer is C
Explanation
The correct answer is C. The risk manager.
Rationale: The risk manager is responsible for identifying and managing potential or actual sources of harm or loss in a healthcare organization. The risk manager would be interested in analyzing the data on zolpidem use and fall rate, implementing preventive measures, and reporting adverse events to regulatory agencies if needed. The surgeon may not be directly involved in prescribing zolpidem or monitoring its effects on postoperative clients. The case manager may not have access to or authority over medication administration policies or practices. The pharmacist may be able to provide information on zolpidem's pharmacokinetics and pharmacodynamics, but may not be able to address the organizational factors that contribute to fall risk.
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