A nurse is planning care for a client who has a newly placed percutaneous endoscopic gastrostomy (PEG) tube and is agitated and confused. The provider prescribes bilateral wrist restraints. Which of the following actions should the nurse plan to take?

Place the client in a supine position.

Remove the restraints every 2 hr.

Secure the straps with a square knot.

Attach the straps to the side rails of the bed frame.

Answer and Explanation

The Correct Answer is B

Rationale

A. Place the client in a supine position: Placing a client supine is not necessary for restraint use and may increase the risk of aspiration, especially in a client with a PEG tube. Positioning should prioritize safety and comfort, typically semi-Fowler’s for feeding.

B. Remove the restraints every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, circulation, range of motion, and the client’s need for continued restraint. Regular release prevents complications such as skin breakdown, nerve injury, or impaired circulation.

C. Secure the straps with a square knot: Restraint straps should be secured using a quick-release knot, not a square knot, to allow rapid removal in an emergency. Using an incorrect knot can delay urgent intervention and compromise safety.

D. Attach the straps to the side rails of the bed frame: Restraints should be attached to the bed frame not the side rails that move, or another fixed point, to prevent injury. Attaching to movable side rails can cause entrapment or worsen injury if the rails are raised or lowered.

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Correct Answer is C

Explanation

Rationale

A. Sublimation: Sublimation involves channeling unacceptable impulses into socially acceptable or constructive activities, such as exercising or creating art. Smoking to manage anxiety does not transform the impulse into a positive behavior, so this does not fit.

B. Projection: Projection occurs when an individual attributes their own unacceptable feelings or impulses onto someone else. The client is not blaming others for their anxiety or behavior, so projection is not demonstrated here.

C. Rationalization: Rationalization involves justifying behaviors with seemingly logical reasons to avoid confronting the true underlying feelings. The client explains smoking as a way to manage anxiety, providing a rational explanation for a behavior that may have deeper psychological or habitual roots.

D. Dissociation: Dissociation involves disconnecting from reality or separating oneself from thoughts, feelings, or identity. The client remains aware of their behavior and feelings, so dissociation is not applicable in this scenario.

A. Stroking the lower abdomen B. Leaning backward when sitting and attempting to urinate C. Performing Kegel exercises prior to urination D. Pouring warm water over the perineum

Correct Answer is D

Explanation

Rationale

A. Stroking the lower abdomen: Stroking the lower abdomen is not an evidence-based technique to stimulate bladder emptying. It may provide minimal sensory feedback but does not effectively trigger the micturition reflex in clients experiencing postoperative urinary retention.

B. Leaning backward when sitting and attempting to urinate: Leaning backward can actually impede proper bladder emptying by kinking the urethra. Proper positioning for urination involves sitting upright or leaning slightly forward to facilitate relaxation of the pelvic floor and urethral alignment.

C. Performing Kegel exercises prior to urination: Kegel exercises strengthen pelvic floor muscles and are useful for improving long-term urinary continence, but performing them immediately prior to attempting urination can tighten the muscles and hinder urine flow. This technique does not promote immediate bladder emptying.

D. Pouring warm water over the perineum: Pouring warm water over the perineum can stimulate sensory nerves and activate the micturition reflex, promoting bladder contraction and facilitating urination. This is a noninvasive, effective technique commonly used for clients experiencing postoperative urinary retention.

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A nurse is planning care for a client who has a newly placed percutaneous endoscopic gastrostomy (PEG) tube and is agitated and confused. The provider prescribes bilateral wrist restraints. Which of the following actions should the nurse plan to take?

Nursing Test Bank

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Explanation

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