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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Gathering personal belongings is appropriate for safekeeping or distribution to family members.

B. Closing the client’s eyes is part of respectful postmortem care.

C. Washing the client’s face is a standard part of preparing the body for viewing.

D. Dentures are typically left in place to maintain facial structure and present a natural appearance for family visitation.

A. "I understand that you decided not to receive blood products." B. "You need to talk with your doctor about this." C. "Not receiving blood will slow down your recovery." D. "Why are you refusing to receive blood products?"

Correct Answer is A

Explanation

A. This response acknowledges the client’s autonomy and decision-making regarding their treatment, which is essential in patient-centered care.

B. While consulting the physician is important, this response may dismiss the client's concerns rather than addressing them directly.

C. This response may appear coercive and could undermine the client’s autonomy by suggesting negative consequences without discussing their concerns.

D. Asking why the client is refusing blood products may come off as confrontational rather than supportive, potentially making the client uncomfortable.

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Body system	Findings
Neurological	Alert and oriented to person, place, and time: deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	Lungs clear
Cardiovascular	Heart rate irregular: Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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