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 C
Explanation
A. Eating turkey sausage for breakfast is incorrect. Processed meats, including turkey sausage, are high in sodium and should be avoided in a low-sodium diet. Even "healthier" alternatives can contain significant amounts of added salt.
B. Putting ketchup on hot dogs is incorrect. Ketchup and hot dogs are both high in sodium, making them poor choices for a client managing hypertension.
C. Using frozen vegetables rather than canned is correct. Canned vegetables often contain added sodium for preservation, while frozen vegetables typically have little to no added salt, making them a healthier option.
D. Using store-bought spaghetti sauce is incorrect. Many commercial pasta sauces contain high levels of sodium, which can contribute to increased blood pressure. A low-sodium alternative, such as homemade sauce with fresh ingredients, would be a better choice.
Correct Answer is B
Explanation
A. Members of a health care team can share a computer password.: This is incorrect. Passwords should never be shared, as doing so can compromise the confidentiality of client information. Each team member should have their own secure login and password.
B. Information regarding client health can be e-mailed if encrypted.: This is correct. According to HIPAA guidelines, it is permissible to email client health information if the email is encrypted and appropriate security measures are taken.
C. A client is restricted from accessing his own medical records.: This is incorrect. Clients have the right to access their own medical records under the Health Insurance Portability and Accountability Act (HIPAA..
D. Unwanted printed health information can be discarded in a trash can.: This is incorrect. Printed health information should be shredded, not simply discarded in the trash, to ensure confidentiality is maintained.
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