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. BUN 18 mg/dL is incorrect. A BUN (blood urea nitrogen) level of 18 mg/dL is within the normal range (typically 7–20 mg/dL) and does not indicate immediate concern in this context. An elevated BUN could indicate dehydration, but this level is not significantly elevated.
B. Serum creatinine 1.0 mg/dL is incorrect. Serum creatinine levels are also within normal limits for most adults, which is around 0.6–1.2 mg/dL, and this finding does not indicate a problem.
C. Urine output 12 mL/hr is correct. A urine output of 12 mL/hr is low and indicates oliguria, which is a concern in the context of dehydration. The normal urine output for an adult is at least 30 mL/hr. A decrease in urine output suggests that the kidneys are not receiving adequate blood flow, which could indicate severe dehydration and requires immediate attention from the provider.
D. Urine specific gravity 1.020 is incorrect. Urine specific gravity of 1.020 is within the normal range (typically 1.005–1.030) and indicates that the kidneys are concentrating urine appropriately, which is not a concerning finding in this case.
Correct Answer is C
Explanation
A. A client who has a sodium intake of 1,200 mg/day.: A sodium intake of 1,200 mg/day is actually within the recommended range for most adults. Therefore, this client does not require a dietitian’s consultation based on this information alone.
B. A client who has a serum albumin level of 4.5 g/dL.: A serum albumin level of 4.5 g/dL is within the normal reference range. There is no immediate concern with this level, so an interprofessional care conference is not necessary for this client.
C. A client who has a body mass index of 32.: A BMI of 32 is classified as obese, which can increase the risk of various health problems. A dietitian’s input can help address dietary modifications to manage weight and improve health outcomes, making an interprofessional care conference appropriate.
D. A client who has a total fat intake of 25% of daily calories.: A fat intake of 25% is within the acceptable range for most adults and does not immediately warrant a referral to a dietitian unless there are other concerns.
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