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. Removing personal protective equipment (PPE. after leaving the room is incorrect because it should always be done before leaving the client's room to ensure the nurse does not accidentally spread the infection. Proper removal of PPE is crucial to preventing transmission.

B. Wearing a gown when assisting the client with personal hygiene is correct. MRSA is typically spread through direct contact, so wearing a gown when providing personal care (e.g., assisting with hygiene. helps prevent the spread of MRSA. Additionally, gloves and other PPE should also be worn.

C. Negative air pressure is typically required for airborne precautions, such as for clients with tuberculosis, but not for MRSA, which is transmitted via contact. Therefore, this is not necessary for MRSA care.

D. Restricting the client's visitors is not necessary unless the client has an infection that requires isolation precautions beyond what is standard for MRSA. MRSA can be controlled with contact precautions, and visitor restrictions are generally not part of standard MRSA isolation.

A. Physical therapist B. Primary care provider C. Occupational therapist D. Social worker

Correct Answer is D

Explanation

A. Referring to a physical therapist is incorrect. Physical therapists focus on improving mobility, strength, and balance, but they do not typically assist with transportation needs or alternative arrangements for follow-up appointments.

B. Referring to a primary care provider is incorrect. While the primary care provider oversees medical care and follow-ups, they do not arrange transportation services or address logistical concerns regarding appointments.

C. Referring to an occupational therapist is incorrect. Occupational therapists help clients regain skills for daily living, including adaptive techniques for driving, but they do not arrange transportation.

D. Referring to a social worker is correct. Social workers help clients identify resources, such as transportation services, to ensure they can attend medical appointments and access necessary care.

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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?

Nursing Test Bank

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