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 correct answer is that the client should press the inner corner of their eye after inserting the drops. This technique is called punctal occlusion and it helps to prevent the eye drops from draining into the tear duct and being absorbed by the rest of the body. This can increase the effectiveness of the eye drops and reduce potential side effects.
Options b, c and d are not correct statements by the client that indicate an understanding of how to self- administer an ophthalmic solution. Raising the eyelid up while looking down to insert the drops, keeping eyes closed for 5 minutes after inserting the drops and inserting the drops in the center of each eye are not recommended techniques for self-administering an ophthalmic solution.
Correct Answer is B
Explanation
The priority intervention for a client with a new diagnosis of terminal cancer is to discuss the client's prior coping mechanisms. This will help the nurse to understand how the client has coped with difficult situations in the past and to develop a plan of care that is tailored to the client's individual needs and preferences.
Options a, c, and d are also important interventions, but they are not the priority. Helping the client to find a local support group, developing a list of goals with the client, and teaching the client to use progressive relaxation techniques can all be helpful in supporting the client's emotional well-being, but they should be implemented after the nurse has assessed the client's coping mechanisms and developed a plan of care.
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