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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is that the nurse should place the base of a vibrating tuning fork on the top of the client's head when performing Weber's test. Weber's test is a screening test for hearing that can detect unilateral (one-sided. conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss)².

Options b, c and d are not correct actions for performing Weber's test. Counting how many seconds a client can hear a tuning fork after it has been struck, placing the base of a vibrating tuning fork on the client's mastoid process and moving a vibrating tuning fork in front of the client's ear canals one after the other are not part of Weber's test.

A. The client stoops slightly forward when moving the walker. B. The client moves the walker ahead 25.4 cm (10 in) with each step. C. The client stands with her elbows slightly ﬂexed while holding the walker. D. The client picks up the walker with each step.

Correct Answer is C

Explanation

When using a two-wheeled walker, the client should stand with their elbows slightly ﬂexed while holding the walker. This allows for proper posture and support while using the walker.

Option a is incorrect because stooping forward can cause strain on the back and neck.

Option b is incorrect because moving the walker too far ahead can cause instability and increase the risk of falls.

Option d is incorrect because picking up the walker with each step can cause fatigue and decrease the eﬀectiveness of the walker.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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