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 B

Explanation

Parenteral nutrition (PN) with high concentrations of dextrose, such as 20%, requires a central venous line for administration to prevent damage to peripheral veins. Therefore, preparing the client for a central venous line is an appropriate action to include in the plan of care.

a. The PN infusion bag should be changed every 24 hours to reduce the risk of infection.

d. Blood glucose levels should be monitored regularly, but not necessarily daily, as PN can aﬀect blood glucose levels.

c. PN and fat emulsions can be administered together in a single infusion.

A. A client who requires teaching prior to discharge. B. A client who is watching a video about the meal services at the facility in their primary language. C. A client who is learning to use an incentive spirometer and has an interpreter present. D. A client who requires administration of a prescribed pain medication.

Correct Answer is A

Explanation

The nurse should provide written materials in the client's primary language for a client who requires teaching prior to discharge. This ensures that the client has access to important information in a language they understand and can refer to after leaving the facility.

b. A client who is watching a video about meal services in their primary language may not require additional written materials.

c. A client who is learning to use an incentive spirometer with the help of an interpreter may not require additional written materials.

d. The administration of a prescribed pain medication does not necessarily require the provision of written materials.

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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

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a group of clients whose primary languages are diﬀerent from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

Correct Answer is A

Explanation

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