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 C
Explanation
Rationale
A. Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.
B. Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.
C. Crackles in lung bases: Crackles heard in the lower lung fields indicate pulmonary fluid accumulation, a common finding in fluid volume excess. Excess intravascular fluid can leak into the alveoli, causing impaired gas exchange and respiratory symptoms. Auscultation of crackles helps identify pulmonary edema early.
D. Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.
Correct Answer is C
Explanation
Rationale
A. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is a normal postoperative finding during the first few hours after surgery. It reflects expected wound healing and does not require immediate reporting.
B. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period due to anesthesia and analgesics. While bowel function should be monitored, this finding is expected and not urgent.
C. Urine output 25 mL/hr: Urine output below 30 mL/hr indicates possible inadequate renal perfusion or early postoperative oliguria. This finding should be reported promptly to the provider for evaluation and potential intervention to prevent acute kidney injury.
D. Heart rate 68/min: A heart rate within normal limits is not concerning in a postoperative client. It does not indicate a complication and does not require immediate provider notification.
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