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.
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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Related Questions
Correct Answer is C
Explanation
The correct answer is that discussing the client's transfer to a long-term care facility with a nurse from another unit is a violation of HIPA
A. HIPAA regulations require that healthcare providers protect the privacy of their clients' personal health information (PHI) and only share it with authorized individuals on a need- to-know basis.
Options a, b and d are not violations of HIPAA. Faxing medical information to the client's provider's office, teaching the client discharge instructions with his partner present and giving a telephone report to a surgical nurse when sending the client to the surgical suite are all acceptable practices under HIPAA regulations.
Correct Answer is B
Explanation
Cellulitis is a contraindication to receiving acupuncture treatment. Acupuncture involves the insertion of needles into the skin, and if the client has an active skin infection such as cellulitis, there is a risk of spreading the infection.
Option a is incorrect because hypertension is not a contraindication to receiving acupuncture.
Option c is incorrect because obesity is not a contraindication to receiving acupuncture.
Option d is incorrect because migraines are not a contraindication to receiving acupuncture; in fact, acupuncture may be used to treat migraines.
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