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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Answer: D. Apply support stockings.

Rationale: Support stockings can help reduce ankle edema by promoting venous return and preventing fluid accumulation in the lower extremities. Diuretics, bedrest, and fluid restriction are not recommended for pregnant clients with ankle edema as they can cause dehydration, thromboembolism, and fetal compromise.

A. A B. B C. C D. D

Correct Answer is {"xRanges":[125.765625,155.765625],"yRanges":[492.609375,522.609375]}

Explanation

The dorsalis pedis artery pulse can be palpated lateral to the extensor hallucis longus tendon (or medially to the extensor digitorum longus tendon) on the dorsal surface of the foot, distal to the dorsal most prominence of the navicular bone which serves as a reliable landmark for palpation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A nurse is monitoring a client's arterial pulses. The nurse should check for a dorsalis pedis pulse in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[125.765625,155.765625],"yRanges":[492.609375,522.609375]}

Explanation

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