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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The nurse should first palpate the abdomen to assess for tenderness and rigidity, which can provide important information about the client's condition. Right lower quadrant pain can be a sign of appendicitis, and abdominal palpation is an important part of the assessment for this condition.
- Administering an antiemetic may help relieve the client's nausea and vomiting, but it is not the first action the nurse should take.
- Offering pain medication may help relieve the client's pain, but it is not the first action the nurse should take.
- Auscultating bowel sounds can provide information about the client's gastrointestinal function, but it is not the first action the nurse should take.
Correct Answer is D
Explanation
The nurse should ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This is a standard procedure for the safe handling and documentation of controlled substances.
a. The nurse should report any discrepancy in the count total of the controlled substance before administration, not after.
b. The wasted portion of the controlled substance should be disposed of according to facility policy, which may not involve placing it in a sharps container.
c. The count total of the controlled substance should be verified before removing the amount needed, not after.
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