A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
Request a prescription renewal from the provider every 36 hr.
Make sure two fingers fit under the restraints.
Check the client's range of motion every 6 hr.
Secure the restraints with a square knot.
The Correct Answer is B
A. Restraint prescriptions typically need to be renewed at least every 24 hours, not every 36 hours, to comply with regulatory standards.
B. Ensuring that two fingers fit under the restraints is essential to confirm that they are not too tight, allowing for circulation and comfort while still securing the client.
C. Checking the client's range of motion should occur more frequently than every 6 hours; ideally, it should be assessed more regularly to prevent complications.
D. Restraints should be secured using a quick-release knot, not a square knot, to ensure they can be removed easily in an emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A BMI of 25–29.9 is categorized as "overweight." This indicates that the client is above the ideal weight range but has not reached the threshold for obesity.
B. Underweight is defined as a BMI below 18.5, so this option does not apply to a BMI of 29.
C. Ideal body weight is generally associated with a BMI between 18.5 and 24.9, which does not include a BMI of 29.
D. Obesity is defined as a BMI of 30 or above. Therefore, a BMI of 29 does not meet the criteria for this classification.
Correct Answer is C
Explanation
A. Urinating after specimen collection can contaminate the stool sample; the client should be instructed to collect the stool first.
B. Stool specimens should be kept cool (usually in a refrigerator) to prevent decomposition, not in a warm area.
C. Avoiding placing toilet tissue in the bedpan after defecation is crucial to prevent contamination of the stool specimen, indicating understanding of proper collection techniques.
D. The typical recommendation for stool specimen collection is usually larger than 1.3 cm (0.5 in) and varies based on the type of test; clarity on this guideline is important.
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