A nurse is caring for a client who is pulling at their abdominal wound drains. The provider prescribes wrist restraints for the client's safety. To which of the following parts of the bed should the nurse secure the restraints?

Head of the bed

Moveable portion of the bed frame

Foot of the bed

Side rails closest to the restraints

Answer and Explanation

The Correct Answer is B

A. Head of the bed: Securing restraints to the head of the bed is unsafe because this part does not move with the client’s position changes. It can create tension, leading to injury or impaired circulation.

B. Moveable portion of the bed frame: The safest method is to secure restraints to a moveable part of the bed frame. This ensures the restraints move with the client when the bed position changes, preventing tightening or loosening that could cause harm.

C. Foot of the bed: Tying restraints to the foot of the bed can cause excessive length of restraint straps and increase the risk of entanglement or injury. It also does not provide stable, controlled positioning during movement.

D. Side rails closest to the restraints: Side rails are not stable anchoring points because they move up and down. Attaching restraints here increases the risk of injury if the side rail is lowered, as it could loosen or tighten the restraint unexpectedly.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Safety: The client has an unsteady gait, dizziness on standing, ecchymosis in multiple healing stages, and abrasions, all of which raise concerns for recurrent falls or possible neglect. Ensuring the client’s immediate safety is the top priority before addressing other needs.
Notify Adult Protective Services: Scattered ecchymoses in different healing stages, poor hygiene, and possible neglect warrant a report to APS for further investigation to ensure the client’s protection.

Rationale for incorrect choices:

Hygiene: While poor hygiene, lice infestation, and odor are evident, these concerns are not immediately life-threatening compared to the safety risks of falls and potential abuse or neglect. They can be addressed after the client is safe and protected.
Nutrition: No clear evidence of malnutrition is provided, though decreased skin turgor suggests possible dehydration. However, nutrition needs are a lower priority than immediate safety concerns related to falls and potential abuse.
Arrange for dietary consult: This intervention would be appropriate later for long-term care planning, but it does not address the client’s most urgent risk factors.
Consult with social services for support: Social services may help coordinate resources, but urgent reporting to APS is needed first because of suspected neglect and abuse indicators.

A. Tilt the client's head away from the side receiving the drops. B. Instill the drops directly onto the cornea of the eye receiving the drops. C. Rest the dominant hand on the client's forehead while instilling the drops. D. Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac.

Correct Answer is C

Explanation

A. Tilt the client's head away from the side receiving the drops: The client’s head should be tilted slightly back and toward the side receiving the drops, not away. Tilting away may cause the medication to run out instead of entering the conjunctival sac.

B. Instill the drops directly onto the cornea of the eye receiving the drops: The cornea is highly sensitive, and placing drops directly on it can cause pain, reflex blinking, or injury. Drops should be placed into the conjunctival sac to ensure comfort and proper absorption.

C. Rest the dominant hand on the client's forehead while instilling the drops: Resting the hand on the forehead stabilizes the dropper, preventing accidental injury if the client moves suddenly. This provides safety and accuracy when administering the medication.

D. Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac: The dropper should be held about 1–2 cm above the sac to avoid touching the eye. Holding it too close increases the risk of contamination or accidental contact with the eye surface.

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A nurse is caring for a client who is pulling at their abdominal wound drains. The provider prescribes wrist restraints for the client's safety. To which of the following parts of the bed should the nurse secure the restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client being admitted into a long-term care facility. Exhibits Complete the following sentence by using the list of options. The nurse should address the client's dropdownfollowed bydropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is preparing to administer ophthalmic drops to a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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