A nurse is caring for a client who is confused and has been placed in wrist restraints.
Which of the following actions should the nurse take while caring for this client? (Select all that apply.)

Check that the client’s restraints are secured with a half-bow knot.

Request that the provider prescribe the restraints as PRN.

Ensure that the client’s wrists are padded.

Loosen the restraints once every 4 hr.

Document client care every 15 min.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale
Checking that the client’s restraints are secured with a half-bow knot is a good practice. This type of knot is secure but can be easily untied, which is important for quick removal of the restraints if necessary.
Choice B rationale
Requesting that the provider prescribe the restraints as PRN is not a good practice. Restraints should only be used as a last resort and must be ordered by a healthcare provider. The order must specify the reason for the restraints and the duration of use.
Choice C rationale
Ensuring that the client’s wrists are padded is a good practice. Padding helps to prevent skin breakdown and nerve damage.
Choice D rationale
Loosening the restraints once every 4 hours is not a good practice. Restraints should be removed or loosened every 2 hours to allow for skin care and assessment, range of motion exercises, and to check for signs of injury.
Choice E rationale

Documenting client care every 15 minutes is a good practice. This includes documenting the client’s behavior, the type and location of restraints, the frequency of care (at least every 2 hours), and the client’s response to the restraints.

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Correct Answer is A

Explanation

The correct answer is Choice A. The client is receiving an oxygen concentration of 28%. Nasal cannulas can deliver oxygen at a flow rate ranging from 1 to 6 liters per minute (L/min), with

each additional liter increasing the fraction of inspired oxygen (FiO2) by 4%. Therefore, at 2 L/min, the client is receiving an oxygen concentration of 28%78.

A. Check that the client lifts the walker and then places it down in front of her. B. Walk in front of the client to guide her in moving the walker. C. Have the client move one leg forward with the walker. D. Make sure that the upper bar of the walker is level with the client’s waist.

Correct Answer is A

Explanation

Choice A rationale

The client should lift the walker and place it down in front of her. This is because lifting the walker provides stability and support as the client moves. It’s important for the client to move the walker first, then step forward to ensure balance and prevent falls.
Choice B rationale
Walking in front of the client to guide her in moving the walker is not the best practice. The client should be allowed to set the pace and the nurse should be beside or slightly behind the client to provide assistance if needed.
Choice C rationale
Having the client move one leg forward with the walker is not the most effective way to use a walker. Both legs should move forward after the walker has been placed down in front of the client.
Choice D rationale
Making sure that the upper bar of the walker is level with the client’s waist is a good practice, but it’s not the best answer for this question. The height of the walker should be adjusted so that the handles are at the level of the client’s wrists when the client’s arms are hanging down. This allows the client to maintain a slight bend in their elbows when holding the handles.

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A nurse is caring for a client who is confused and has been placed in wrist restraints. Which of the following actions should the nurse take while caring for this client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

Correct Answer is A

Explanation

A nurse is assisting an older adult client in the hallway for the first time since admission. The client has brought a standard walker from home.To ensure the client’s safety and proper use of the walker, which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is caring for a client who is confused and has been placed in wrist restraints.
Which of the following actions should the nurse take while caring for this client? (Select all that apply.)