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. Using a filter needle to aspirate the medication from an ampule is appropriate because it prevents glass particles from entering the syringe when the ampule is broken.
B. Injecting air into an ampule is unnecessary and can be dangerous as ampules are designed to be opened directly without air injection.
C. Cleansing the tip of the ampule should occur before opening it, not after, to ensure sterility is maintained.
D. Adding diluent is not a standard practice unless the specific medication requires reconstitution as directed by a healthcare provider.
Correct Answer is B
Explanation
A. While it is important to restrict access to medical records, it is not solely the risk manager's role to give permission; the policy should be followed regarding patient information access.
B. Reminding the nurse that only those directly involved in the client's care should access their medical record upholds confidentiality and patient privacy standards.
C. Completing an incident report is a more formal step and might be warranted later, but initially addressing the behavior directly is more appropriate.
D. Contacting security would be an extreme response; addressing the situation with the nurse first is typically the best course of action.
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