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.
Attach the straps to the side rails of the bed frame.
Secure the straps with a square knot.
Remove the restraints every 2 hr.
The Correct Answer is D
A. Place the client in a supine position: The position should prioritize the client’s safety and comfort, considering their condition and the risk of aspiration or discomfort. A supine position may not be the most appropriate for this client’s agitation or confusion.
B. Attach the straps to the side rails of the bed frame: Attaching the restraints to the side rails could be dangerous, as it may cause injury or further agitation. Restraints should be attached to a non-movable part of the bed to ensure the client’s safety and prevent injury due to entrapment.
C. Secure the straps with a square knot: Restraints should not be secured with a square knot, as this could make them difficult to release quickly in an emergency. Instead, the restraint should be fastened in a way that allows for quick removal when needed to ensure the client's safety.
D. Remove the restraints every 2 hr: It is essential to remove restraints at least every 2 hours to check for any signs of injury, provide comfort, and ensure circulation. Removing restraints allows for proper skin care and reduces the risk of complications like pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Occupational therapist: An occupational therapist specializes in helping clients with activities of daily living (ADLs), such as dressing, grooming, and bathing. An occupational therapist can assist in creating strategies or using adaptive equipment to help the client become more independent with dressing.
B. Respiratory therapist: A respiratory therapist focuses on managing respiratory issues and providing treatments like oxygen therapy or breathing exercises. This is not directly related to assisting with dressing, so they are not the appropriate team member for this issue.
C. Social worker: While a social worker can assist with psychosocial issues and discharge planning, they are not typically involved in helping with daily functional tasks like dressing. They would not be the primary provider for this need.
D. Physical therapist: A physical therapist focuses on improving movement, strength, and mobility, particularly related to walking and physical rehabilitation. While they may assist with mobility following surgery, they are not primarily focused on ADLs like dressing.
Correct Answer is D
Explanation
A. Depression: Depression typically involves feelings of sadness, despair, and withdrawal. The client's statement about wanting comfort, rather than prolonged sadness, reflects acceptance, not depression.
B. Bargaining: Bargaining is when individuals try to make deals to reverse their situation, often asking for more time. The client’s statement reflects a decision to stop treatment, not bargaining for more time.
C. Denial: Denial involves refusing to acknowledge the reality of the situation. The client’s statement shows recognition of their condition and prioritizing comfort, which shows acceptance rather than denial.
D. Acceptance: In the acceptance stage, individuals come to terms with their diagnosis and focus on achieving peace. The client’s request for comfort care is consistent with acceptance, where they focus on making the most of their time.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.