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 C
Explanation
A. Milk the chest tube at least three times a day: Milking is generally not recommended as it can increase intrathoracic pressure and damage lung tissue. It should only be done with a provider’s order and specific indication.
B. Empty the drainage collection chamber when full: The collection chamber is a closed system and should not be emptied. When full, the entire drainage unit should be replaced to maintain sterility.
C. Ensure intermittent bubbling is present in the water seal chamber: Intermittent bubbling in the water seal chamber is expected during expiration or coughing, indicating air leaving the pleural space. However, continuous bubbling may suggest an air leak and requires evaluation.
D. Clamp the chest tube when transferring the client from bed to the chair: Clamping the tube is contraindicated during transport, as it can cause tension pneumothorax. The system should remain unclamped and below chest level.
Correct Answer is B
Explanation
A. Notify the primary care provider: Notifying the provider is important, but first, the nurse should assess the client’s condition by obtaining vital signs. This helps determine if immediate intervention is needed, like administering antidotes or treatments.
B. Obtain the client's vital signs: The first step is assessing the client’s physical status by checking vital signs. This helps identify signs of toxicity or immediate adverse effects from the overdose, guiding further actions.
C. Educate the client about potential adverse effects: Education is important, but it’s not the first priority in the case of an overdose. The nurse should first focus on assessing and stabilizing the client before providing information on potential adverse effects.
D. Complete an incident report: While an incident report is necessary, it is not the immediate priority. The nurse must first ensure the client’s safety and health by assessing and managing the overdose.
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