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 D

Explanation

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

A. "I can take antacids at the same time as this medication." B. "I have to take this medication on an empty stomach." C. "I should expect to have diarrhea while taking this medication." D. "I will need to remain upright for 1 hour after taking the medication."

Correct Answer is B

Explanation

A. "I can take antacids at the same time as this medication.": This is incorrect. Pantoprazole is a proton pump inhibitor (PPI), and taking antacids at the same time can interfere with the medication's effectiveness. It is generally recommended to space out antacids and PPIs by at least 1 hour.

B. "I have to take this medication on an empty stomach.": This is correct. Pantoprazole should be taken on an empty stomach, typically 30 minutes before breakfast, to optimize absorption and effectiveness.

C. "I should expect to have diarrhea while taking this medication.": Diarrhea is not a common side effect of pantoprazole. While side effects such as headache, nausea, and abdominal pain are more common, diarrhea is not typically expected.

D. "I will need to remain upright for 1 hour after taking the medication.": This is incorrect. While it is generally advised to remain upright for a period after taking medications like bisphosphonates, it is not required for pantoprazole. The main instruction for pantoprazole is to take it on an empty stomach before eating.

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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?

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