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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Antimicrobial dressings are typically used for wounds that are infected or at high risk of infection. A stage I pressure ulcer, which involves intact skin with non-blanchable redness, would not typically require an antimicrobial dressing.
Choice B rationale
Wet-to-dry dressings are used for mechanical debridement of wounds with necrotic tissue. A stage I pressure ulcer does not involve necrotic tissue, so this type of dressing would not be appropriate.
Choice C rationale
Transparent dressings are often used for stage I pressure ulcers. They provide a protective layer over the wound, promoting a moist environment and facilitating the healing process.
Choice D rationale

Dry, sterile dressings are typically used for wounds that need to be kept dry. A stage I pressure ulcer benefits from a moist healing environment, which can be provided by a transparent dressing.

A. A client who has community-acquired pneumonia with copious respiratory secretions B. A client who has AIDS and is coughing up blood C. A client who has Guillain-Barré syndrome and is on a ventilator D. A client who has bronchitis and a tracheostomy

Correct Answer is A

Explanation

Choice A rationale
A client who has community-acquired pneumonia with copious respiratory secretions should be assigned to the private room. This is because pneumonia, especially with copious respiratory secretions, can be transmitted through the air, and therefore requires airborne precautions.
Choice B rationale
A client who has AIDS and is coughing up blood may not necessarily require a private room for airborne precautions. While AIDS is a serious condition, it is not primarily transmitted through the air. Instead, it is transmitted through direct contact with bodily fluids, particularly blood, semen, vaginal fluids, and breast milk.
Choice C rationale
A client who has Guillain-Barré syndrome and is on a ventilator would not necessarily require a private room for airborne precautions. Guillain-Barré syndrome is a neurological disorder, not an infectious disease, and it is not transmitted from person to person.
Choice D rationale

A client who has bronchitis and a tracheostomy may not necessarily require a private room for airborne precautions. While bronchitis can be caused by an infection, it is typically transmitted through direct contact or droplet transmission, not through the air.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 nurse is performing wound care for an older adult patient who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Correct Answer is C

Explanation

A nurse is assisting a charge nurse with room assignments. There is one private room available on the unit to accommodate a client who needs airborne precautions.Which client should be assigned to this room?

Correct Answer is A

Explanation

A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?

A nurse is reviewing a client’s prescriptions and notices that the dosage of one medication is three times the usual dose.The prescribing provider is unavailable for several days. What should the nurse do next?

A nurse is preparing to administer aspirin 650 mg PO. The available medication is aspirin 325 mg tablets. How many tablets should the nurse administer?

A nurse is assessing an elderly patient receiving palliative care who exhibits Cheyne-Stokes respirations. Which of the following characteristics should the nurse identify as indicative of this respiratory pattern?

A nurse is preparing to administer amoxicillin 300 mg PO. The available medication is amoxicillin oral solution 250 mg/5 mL. How many mL should the nurse administer?

A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. What actions should the nurse plan to take?

A nurse is reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night.Which statement indicates that the client understands the instructions?

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.)

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.)