A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

Contact the provider within 48 hr to obtain a prescription for the restraints.

Remove the restraints from the client's wrists every 2 hr.

Check that one finger will fit between the client's wrists and the restraints.

Fasten the restraints' ties to the bed's side rails.

Answer and Explanation

The Correct Answer is B

A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.

B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.

C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.

D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.

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Correct Answer is B

Explanation

A. BUN 20 mg/dL: This is not specific to HELLP syndrome. A BUN level of 20 mg/dL is within the normal range and does not indicate the presence of HELLP syndrome, which is associated with liver dysfunction and low platelet count.

B. Platelet count 77,000/mm3: This is correct. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets) is characterized by a low platelet count, often less than 100,000/mm3, which is a critical indicator of this condition.

C. Hemoglobin 12 g/dL: This is a normal hemoglobin level and is not typically associated with HELLP syndrome, where hemolysis (destruction of red blood cells) can cause anemia, which would lower hemoglobin levels.

D. WBC count 18,000/mm3: While an elevated WBC count can indicate infection or inflammation, it is not specifically associated with HELLP syndrome. The hallmark features of HELLP syndrome are low platelets and liver enzyme elevation, not elevated WBC.

A. Respiratory rate 16/min B. Blood pressure 110/70 mm Hg C. 400 mL of drainage in the collection chamber within 4 hr D. Fluctuation in the water seal chamber with respiration

Correct Answer is C

Explanation

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

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A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

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