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
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Correct Answer is C
Explanation
A. Applying lidocaine gel to the urethra may provide additional lubrication but does not address the immediate issue of resistance during catheter insertion.
B. Inflating the catheter's balloon is inappropriate at this stage, as the catheter is not properly positioned for urine flow, and doing so could cause injury.
C. Lowering the penis to a 45° angle helps to straighten the urethra and can facilitate easier passage of the catheter, making it the most appropriate action.
D. Twisting the catheter gently is not recommended, as this may cause trauma to the urethra or increase discomfort without resolving the resistance issue.
Correct Answer is C
Explanation
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
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