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
Related Questions
Correct Answer is B
Explanation
The correct answer is that the nurse should include information about the effectiveness of the last dose of pain medication in the hand-off report when transferring a client to a long-term care facility. This information is important for the receiving facility to continue managing the client's pain effectively.
Options a, c and d are not essential information to include in the hand-off report. The time of the client's last bath, the number of family members who have visited and the frequency of previous vital sign measurement are not critical for ensuring continuity of care during the transfer.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today