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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Apply an ice pack to the affected extremity for 20 min every 2 hr.: Applying ice to the affected extremity can help reduce inflammation and discomfort associated with deep-vein thrombosis (DVT). This method is often recommended to decrease swelling and prevent further complications.
B. Massage the affected extremity every 4 hr.: Massage should be avoided in cases of DVT as it can dislodge the thrombus, leading to a pulmonary embolism or other life-threatening complications.
C. Administer aspirin for pain.: Aspirin is not recommended for clients on anticoagulant therapy, as it can increase the risk of bleeding. Other pain relief options should be considered that do not interact with anticoagulants.
D. Initiate bed rest.: While limited activity is necessary to prevent the risk of embolism, complete bed rest is not typically recommended. Early ambulation (when safe. is often encouraged to prevent complications like venous stasis.
Correct Answer is A
Explanation
A. Drying hands thoroughly from fingers to wrist is correct. Proper drying technique is important because residual moisture can harbor bacteria, and drying from fingers to wrist prevents recontamination of clean areas by water dripping from contaminated areas.
B. Holding hands slightly higher than the elbows when using running water is incorrect. The proper technique is to hold hands lower than the elbows to allow water to flow downward, preventing recontamination of clean areas by dirty water.
C. Washing hands under running water for at least 10 seconds is incorrect. The recommended duration for effective handwashing is at least 20 seconds with soap and water to ensure the removal of pathogens.
D. Cleaning hands with alcohol-based hand gel for 16 seconds is incorrect. The recommended time for using alcohol-based hand rubs is at least 20 seconds, ensuring thorough coverage of all surfaces for effective pathogen removal.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.