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. Taking a 1-hour nap each day may disrupt the client's sleep-wake cycle and make it more difficult to sleep at night.
B. Drinking a glass of milk before bedtime can promote sleep because milk contains tryptophan, an amino acid that can help induce sleep.
C. Taking a long walk before bedtime may increase the client's energy level and make it more difficult to sleep.
D. Watching television in bed can disrupt the client's sleep-wake cycle and make it more difficult to sleep.
Correct Answer is D
Explanation
Rationale:
A. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
B. This response is judgmental and may not support the client's autonomy in making healthcare decisions.
C. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
D. This response acknowledges the client's decision and supports the client in discussing their decision with loved ones.
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