A nurse is observing a client who is in four-point restraints for violent and self-destructive behavior. Which of the following actions should the nurse take when using four-point restraints?
Assess the client every hr for circulation, possible injury, and readiness for discontinuation.
Check the client's peripheral pulses and skin integrity every 15 min.
Assist the client with passive range of motion exercises every 3 hr.
Attach the extremity restraint straps to the bed rails using a quick-release buckle.
The Correct Answer is B
A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation: While regular assessment is necessary, it should be done more frequently than every hour. A check every 15-30 minutes is recommended for safety.
B. Check the client's peripheral pulses and skin integrity every 15 min: Frequent assessments of circulation, skin integrity, and injury help prevent complications like tissue damage or nerve impairment.
C. Assist the client with passive range of motion exercises every 3 hr: Passive range of motion exercises should be done more frequently than every 3 hours to prevent stiffness and joint contractures.
D. Attach the extremity restraint straps to the bed rails using a quick-release buckle: Restraints should never be attached to bed rails, as this increases injury risk. Straps should be secured to a stationary part of the bed frame.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "You should use woolen blankets on your bed": Woolen blankets are highly flammable and pose a fire risk when oxygen is in use. Clients should avoid using woolen or synthetic materials near oxygen tanks and instead use materials that are less likely to catch fire.
B. "You should purchase a fire extinguisher for your home": Oxygen is highly flammable, and having a fire extinguisher readily available in the home is crucial for safety. The nurse should encourage the client to keep a fire extinguisher nearby in case of any oxygen-related fire emergencies.
C. "You will no longer be able to use an electric razor": Electric razors are safe to use while on oxygen therapy, as they are not typically a fire hazard. However, clients should avoid using razors that require flammable substances, such as shaving cream, around oxygen.
D. "Family members who smoke must do so at least 6 feet away from the oxygen tank": Smoking near oxygen tanks is extremely dangerous, and family members should avoid smoking entirely in areas where oxygen is in use. It is important to maintain a safe distance of at least 10 feet or more from oxygen sources when smoking.
Correct Answer is A
Explanation
A. Holds linens close to the body: Holding linens close to the body reduces the risk of contamination and ensures that the linens do not touch potentially unclean surfaces. This practice helps maintain medical asepsis by preventing the spread of microorganisms.
B. Shakes soiled linens before placing them in the hamper: Shaking soiled linens can cause microorganisms to become airborne and spread. To maintain asepsis, linens should be handled gently and placed directly into the hamper without shaking.
C. Puts unneeded clean linens in the hamper: Clean linens should not be placed in the hamper as they could become contaminated. Clean linens should be stored in a clean area to maintain their aseptic state until needed.
D. Places soiled linens on the floor: Placing soiled linens on the floor introduces the risk of contamination, as the floor is not considered a clean surface. Soiled linens should be placed directly into a designated container to maintain medical asepsis.
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