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 C

Explanation

The correct answer is C. Increased urinary output indicates that furosemide, a loop diuretic, is effective in reducing fluid retention and edema in clients with heart failure. The other findings are not indicative of furosemide effectiveness and may suggest adverse effects or complications. Decreased BUN level may indicate overhydration or liver dysfunction. Decreased hemoglobin level may indicate anemia or bleeding. Increased weight of 0.91 kg (2 lb) may indicate fluid overload or worsening heart failure.

A. Uses a firm-bristled toothbrush B. Increased intake of green, leafy vegetables C. Drinks 2,500 mL of fluid per day D. Wears a face mask around others

Correct Answer is A

Explanation

The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.

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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 collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is A

Explanation

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