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 C

Explanation

Choice A rationale
Placing a 1-inch needle on the syringe is not appropriate for an intradermal injection such as a tuberculin skin test. Intradermal injections require a much shorter needle, typically 1/4 to 1/2 inch in length.
Choice B rationale
Holding the syringe at a 20° angle to the client’s skin is not correct for an intradermal injection. For an intradermal injection, the syringe should be held at a much shallower angle, typically about 5 to 15 degrees.
Choice C rationale

Drawing up 0.1 mL of purified protein derivative (PPD) from the vial is the correct action when preparing to administer a tuberculin skin test. This is the standard amount of PPD used for a tuberculin skin test.
Choice D rationale
Pinching the skin at the chosen site with the non-dominant hand before inserting the needle is not typically done for an intradermal injection. Instead, the skin is usually stretched taut to provide a flat surface for the injection.

A. “I’ll use a humidifier beside my bed at night.”. B. “I am going to try to lose about 50 pounds.”. C. “I’ll sleep better if I take a sleeping pill at night.”. D. “I am going to have a glass of red wine before bedtime.”.

Correct Answer is B

Explanation

Choice A rationale
Using a humidifier beside the bed at night may not necessarily decrease the number of apneic episodes in a client with obstructive sleep apnea. While a humidifier can help moisten the airways and may provide some relief from symptoms such as dry mouth or throat, it does not address the underlying issue of airway obstruction.
Choice B rationale
Losing weight can indeed help decrease the number of apneic episodes in a client with obstructive sleep apnea. Obesity is a major risk factor for sleep apnea, as excess fat tissue can thicken the wall of the windpipe, making it narrower and making it harder to keep open.
Therefore, losing weight can help reduce this fat and widen the airway, leading to fewer apneic episodes.
Choice C rationale
Taking a sleeping pill at night may actually worsen obstructive sleep apnea. While it might help the client fall asleep, it can also relax the muscles of the throat, which can make the airway more likely to collapse during sleep, leading to more apneic episodes.

Choice D rationale
Drinking a glass of red wine before bedtime is not recommended for a client with obstructive sleep apnea. Alcohol can relax the muscles in the throat and can disrupt the normal sleep cycle, both of which can lead to more apneic episodes.

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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.)

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Correct Answer is C

Explanation

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Correct Answer is B

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.)