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 D

Explanation

A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.

A. The client leans on the crutches for support while standing still. B. The client advances the unaffected leg first while climbing stairs. C. The client stands 5 cm (2 in) from the front of a chair before sitting. D. The client bears weight on their axilla while standing in the tripod position.

Correct Answer is B

Explanation

A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

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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

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