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
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Correct Answer is D
Explanation
The correct answer is D.
Reduced fat in the stools. Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas, which are lacking in most people with cystic fibrosis due to excess mucus production that clogs the pancreatic ducts. By taking pancrelipase, the child can improve their digestion of food and absorb more nutrients, especially fat and fat-soluble vitamins. This will result in reduced fat in the stools, which is a sign of pancreatic insufficiency.
Correct Answer is C
Explanation
The correct answer is C. Observe the client during and after meals. Bulimia nervosa is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The nurse should monitor the client for signs of purging, such as frequent trips to the bathroom, and provide support and supervision during and after meals to prevent this behavior . This is a priority intervention that addresses the client's physical health and safety.
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