A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Assess skin temperature and color before applying the restraints.

Ensure that the client's bed is in the lowest position.

Secure restraints to allow three fingers to slide under the restraints.

Pad bony prominences before applying the restraints.

Attach the client's restraints to the bed rail.

Answer and Explanation

Correct Answer : A,B,C,D

When planning care for a client who has a prescription for extremity restraints on both wrists, the nurse should assess the client's skin temperature and color before applying the restraints to ensure that there is no circulation impairment. The nurse should also ensure that the client's bed is in the lowest position to prevent falls. The restraints should be secured to allow three fingers to slide under them to prevent injury and ensure proper circulation. Bony prominences should be padded before applying the restraints to prevent pressure injuries.

Option e is incorrect because attaching the client's restraints to the bed rail can cause injury if the bed rail is moved or adjusted.

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Correct Answer is D

Explanation

The nurse should plan to use the client's telephone number to confirm their identity. This is because the telephone number is a unique identifier that is directly associated with the client and can be easily verified. By comparing the client's telephone number with the information on the medication administration record or electronic health record, the nurse can ensure that the right medication is given to the right patient.
Explanation:
a) The client's room number is not a reliable method to confirm the client's identity because multiple clients may be assigned to the same room, and there is a possibility of room changes or transfers.
b) The client's admitting diagnosis is not a suitable method to confirm identity as it does not provide specific information about the individual patient.
c) The name of the client's next of kin is not a reliable method to confirm the client's identity as it refers to a family member or emergency contact, not the client themselves. Additionally, next of kin information may not always be up to date or readily available.

A. Use a cuﬀ with a width that is about 60% of the client's arm circumference. B. Apply the cuﬀ above the client's antecubital fossa. C. Have the client sit with his arm resting above the level of his heart. D. Release the pressure on the client's arm 5 to 6 mm per second.

Correct Answer is A

Explanation

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

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