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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Rationale
A. "Empty the ostomy pouch when it becomes one-third full of contents.": Emptying the pouch before it becomes too full prevents leakage, skin irritation, and discomfort. Regular emptying supports hygiene and maintains appliance adherence, which is essential for stoma care.
B. "Expect the stoma to turn a purple-blue color as it heals.": A healthy stoma should be pink to red, indicating good perfusion. Purple-blue discoloration may indicate ischemia or compromised blood flow, which requires immediate provider notification.
C. "Place a piece of gauze over the stoma while changing the pouch.": Gauze is not necessary and may interfere with proper pouch application. Direct handling with clean technique and using the appliance as designed is sufficient for maintaining hygiene and protecting the stoma.
D. "Cut the opening of the pouch 1/8 of an inch larger than the stoma.": Ensuring the pouch opening is slightly larger than the stoma protects peristomal skin from contact with effluent while maintaining a secure fit. Accurate sizing is critical for preventing skin breakdown and leakage.
E. "Use povidone-iodine to clean around the stoma.": Povidone-iodine is harsh and can irritate peristomal skin. Gentle washing with warm water and mild soap is recommended to preserve skin integrity and prevent irritation.
Correct Answer is ["C","D","E","G"]
Explanation
Rationale
A. Reposition the client every 3 hr: Repositioning should be done every 2 hours for clients at risk of skin breakdown, not every 3 hours. Longer intervals increase the risk of pressure injuries, particularly in clients with limited mobility and incontinence.
B. Place the client on a donut-shaped cushion: Donut-shaped cushions can actually increase pressure on surrounding tissue and contribute to skin breakdown. Pressure-redistribution surfaces are safer and more effective for preventing pressure injuries.
C. Elevate the head of the bed to 45°: Elevating the head of the bed to no more than 30–45° reduces the risk of shear and friction on the sacral area while promoting comfort. Proper positioning helps protect skin integrity, especially in incontinent clients.
D. Request a consult with a registered dietitian: Adequate nutrition is essential for skin health and healing. A dietitian can provide recommendations to ensure sufficient protein, calories, and nutrients to support skin integrity and prevent pressure injuries in clients with diabetes and limited mobility.
E. Provide a support pressure-redistribution surface: Specialty mattresses or overlays redistribute pressure over bony prominences, reducing the risk of pressure injuries. These surfaces are critical for clients who are immobile or incontinent.
F. Perform a skin risk assessment weekly: Skin assessments should be performed daily, not weekly, for clients at high risk. Frequent assessment allows early detection of pressure injury development.
G. Use a moisture barrier ointment after cleaning the client's skin: Barrier ointments protect the skin from moisture associated with urinary and fecal incontinence. Regular application after cleansing helps prevent moisture-associated skin damage and breakdown.
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