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. "Give the client a straw to use for drinking" is incorrect. Straws are not recommended for clients with dysphagia because they can increase the risk of aspiration. It is better to use a cup to control the amount of liquid ingested and reduce choking risk.

B. "Place oral suction equipment next to the client's bedside" is correct. For clients with dysphagia, having oral suction equipment readily available can help clear the airway quickly in case of aspiration or choking. It is an important safety measure in the management of dysphagia.

C. "Provide thin liquids to help the client swallow" is incorrect. Thin liquids can increase the risk of aspiration for clients with dysphagia. It is often recommended to provide thickened liquids, as they are easier to swallow and less likely to be aspirated.

D. "Use a needleless syringe to instill feedings" is incorrect. The use of a needleless syringe for feeding is generally not appropriate for clients with dysphagia unless specifically recommended for feeding via a tube. Otherwise, feeding should be done carefully with consideration for the type and consistency of the food.

A. "My partner and I will use petroleum jelly with latex condoms." B. "My partner and I will both use a condom during intercourse." C. "I will be able to remove my contraceptive sponge immediately after intercourse." D. "My partner will use condoms with spermicides, which works better."

Correct Answer is D

Explanation

A. "My partner and I will use petroleum jelly with latex condoms.": Petroleum jelly should not be used with latex condoms as it can weaken the latex material, increasing the risk of condom breakage. Water-based lubricants are recommended with latex condoms.

B. "My partner and I will both use a condom during intercourse.": This is not necessary or recommended. Only one condom is needed, and using two (male and female condom) may cause friction and increase the likelihood of breakage.

C. "I will be able to remove my contraceptive sponge immediately after intercourse.": The sponge should be left in place for at least 6 hours after intercourse to allow its spermicide to be effective. Removing it immediately could reduce the effectiveness of the contraceptive.

D. "My partner will use condoms with spermicides, which works better.": This statement demonstrates understanding. Using condoms with spermicides can be an effective form of contraception, as the spermicide helps to kill or immobilize sperm, providing an additional layer of protection.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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