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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Disclosing health information to an insurance agency without written consent is a violation of client confidentiality.
B. Disclosing health information to a family member without written consent is a violation of client confidentiality.
C. Disclosing health information to a medical interpreter service on behalf of a client is permissible under HIPAA regulations, as long as the interpreter is bound by confidentiality requirements.
D. Disclosing health information to an employer without written consent is a violation of client confidentiality.
Correct Answer is ["D","E"]
Explanation
Rationale:
A. These neurological findings are within normal limits and do not require immediate follow-up.
B. These musculoskeletal findings are not indicative of an emergency and can be addressed during routine care.
C. Clear lung sounds are a normal finding and do not require immediate follow-up.
D. An irregular heart rate may indicate an arrhythmia or other cardiovascular issue that requires further assessment and intervention.
E. Hyperactive bowel sounds can indicate a variety of gastrointestinal issues, including bowel obstruction or ileus, which may require immediate intervention or further investigation.
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