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.
Check the client's range of motion every 6 hr.
Secure the restraints with a square knot.
Make sure two fingers fit under the restraints.
The Correct Answer is D
Rationale:
A. Wrist restraint orders typically require renewal every 24 hours, not every 36 hours.
B. Checking the client's range of motion every 6 hours is not specific to the use of wrist restraints.
C. Secure the restraints with a quick-release knot, not a square knot, to allow for quick removal in case of emergency.
D. Making sure two fingers fit under the restraints is important to ensure that they are not too tight and do not cause injury to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.
B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.
C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.
D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.
Correct Answer is C
Explanation
Rationale:
A. This response dismisses the concerns of the assistant personnel and is not supportive.
B. This response minimizes the assistant personnel's concerns and does not acknowledge their feelings.
C. This response acknowledges the assistant personnel's concerns and opens the door for further discussion.
D. This response does not address the assistant personnel's concerns and suggests a formal complaint as the only solution. It is not supportive or collaborative.
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