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 B
Explanation
After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems.
Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning off electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.
Correct Answer is A
Explanation
When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.
Option b is incorrect because offering the client sips of a citrus flavored soda may not be appropriate for all clients and should be based on individual preferences and needs.
Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.
Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.
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