A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Check that the restraint is tied to a fixed frame of the bed.

Pad bony prominences on the wrist.

Remove the restraint every 4 hr to allow movement.

Tie the restraint with a knot that will tighten when pulled.

Answer and Explanation

The Correct Answer is B

A.   Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B.   Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C.   Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D.   Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.

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Correct Answer is C

Explanation

A. Obscure the client's name with a marker prior to disposal: While obscuring the client's name is better than not doing anything, it does not fully protect their confidential information. The paper could still be read by someone with access to it.
B. Place the paper in a trash can at the nurses' station: This action does not ensure the proper disposal of confidential information. It could be accessible to unauthorized individuals and breach the client's privacy.
C. Shred the paper in a secure container: Correct. Shredding confidential information is the best way to ensure that it cannot be accessed or read by unauthorized individuals.
D. Secure the paper in the nurse's personal locker: While securing the paper in a personal locker is better than leaving it exposed, it is not the most secure method of disposal for confidential
information.

A. Discontinued medications B. Resolved health conditions C. Frequency of vital sign collection D. Completed nursing interventions E. None F. None

Correct Answer is B

Explanation

A. Discontinued medications are documented in the medical record but are not the primary focus of the transfer report.
B. Resolved health conditions should be included in the transfer report so the receiving facility has a clear understanding of the client’s current health status and any changes in care needs.
C. Frequency of vital sign collection is part of ongoing care but is not the most critical information to communicate during transfer.
D. Completed nursing interventions are documented in the record but do not need to be emphasized in the transfer report.

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A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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