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
Choice A reason:
At the hip region is incorrect because it does not specify any clinical manifestation indicative of scoliosis.
Choice B reason
Uneven shoulder and pelvic heights are the correct position. Scoliosis is a condition characterized by an abnormal lateral curvature of the spine, often causing the spine to appear as an "S" or "C" shape when viewed from the back. When performing scoliosis screenings, the school nurse should look for signs that may indicate scoliosis, such as uneven shoulder and pelvic heights.
Choice C reason:
United tinge of moben of the hips is incorrect because it does not describe a known clinical manifestation of scoliosis and appears to contain typographical errors.
Choice D reason:
Exaggerated curvature of the sacrum is incorrect because it is not a characteristic clinical manifestation of scoliosis. The curvature of the sacrum is normal and not related to scoliosis.
Correct Answer is ["A","B","C","F","G","I","J"]
Explanation
A.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2.This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
B.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C.The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
D.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
E.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
F.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
G.The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.
H.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
I.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
J.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.
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