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 C
Explanation
Rationale:
A. Rapid chewing is not a manifestation of dysphagia.
B. Increased hunger is not a manifestation of dysphagia.
C. A garbled voice can be a manifestation of dysphagia, as it may indicate difficulty swallowing or speaking.
D. Sneezing is not a manifestation of dysphagia.
Correct Answer is B
Explanation
Rationale:
A. Drinking an average of 2,000 milliliters of water daily is a healthy habit that promotes bowel elimination.
B. Taking a prescribed opioid pain medication at bedtime can cause constipation and impaired bowel elimination.
C. Eating apples and black-eyed peas is a healthy dietary choice that promotes bowel elimination.
D. Drinking two hot cups of coffee each morning can promote bowel elimination for some individuals.
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