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
The correct answer is choice b. I will need to remain upright for 1 hour after taking the medication.
Choice A rationale:
Pantoprazole can be taken with or without food, so it does not need to be taken on an empty stomach.
Choice B rationale:
Remaining upright for at least 1 hour after taking pantoprazole helps prevent acid reflux and ensures the medication works effectively.
Choice C rationale:
Diarrhea is a possible side effect of pantoprazole, but it is not an expected outcome for all patients. If diarrhea occurs, it should be reported to a healthcare provider.
Choice D rationale:
Antacids can be taken with pantoprazole, but it is generally recommended to take them at different times to avoid potential interactions.
Correct Answer is C
Explanation
The correct answer is C.
Check the child for oral injuries. The rationale is that during a tonic-clonic seizure, the child may bite their tongue, cheek or lips and cause bleeding or damage to their oral tissues. The nurse should inspect the child's mouth for any injuries and provide appropriate care.
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