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 C

Explanation

A. Patient care technician is incorrect. A patient care technician (PCT) is typically responsible for assisting with basic care tasks, such as taking vital signs or helping with personal hygiene. A PCT is not qualified to assess or manage medication interactions.

B. Psychologist is incorrect. A psychologist specializes in mental health and behavior but does not have the expertise to manage or review medication interactions.

C. Advanced practice nurse is correct. An advanced practice nurse (APN), such as a nurse practitioner, has advanced education and training in pharmacology and the management of complex medication regimens. They can assess potential medication interactions and provide guidance on safe medication use.

D. Social worker is incorrect. While a social worker provides support in areas like coping with illness and accessing resources, they are not typically involved in managing or reviewing medication interactions.

A. Place the client in an orthopneic position. B. Provide the client with three large meals each day. C. Encourage the client to cough and deep breathe once every 8 hr. D. Limit fluid intake to 1,000 ml daily.

Correct Answer is A

Explanation

A. Placing the client in an orthopneic position is correct. The orthopneic position (sitting upright and leaning forward. helps clients with COPD breathe more easily by maximizing lung expansion and easing the work of breathing. This position is often used in clients with chronic respiratory conditions to alleviate dyspnea.

B. Providing the client with three large meals is incorrect. Clients with COPD may have difficulty eating large meals because it can interfere with breathing due to increased diaphragm pressure. Instead, small, frequent meals are recommended to reduce the workload on the respiratory system.

C. Encouraging the client to cough and deep breathe once every 8 hr is incorrect. In clients with COPD, frequent coughing and deep breathing exercises are important to promote airway clearance and lung expansion. The nurse should encourage these activities more often than every 8 hours, especially to help clear mucus.

D. Limiting fluid intake to 1,000 ml daily is incorrect. Adequate hydration is essential in COPD clients to help thin secretions and promote easier expectoration. A restriction on fluids could lead to thickened mucus and worsened respiratory status.

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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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