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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.
Option b is incorrect because the nurse should first clean the incision and then clean the drain site.
Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.
Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.
Correct Answer is B
Explanation
The correct answer is that the nurse should complete an incident report. An incident report is a formal record of an unexpected event that occurred in a healthcare facility. It is important for the nurse to document the details of the visitor's fall, including the date, time, location and any witnesses. This information can be used to identify and address any safety hazards that may have contributed to the fall.
Options a, c and d are not appropriate actions for the nurse to take in this situation. Administering acetaminophen to the client is not relevant to the visitor's fall. Sending the visitor to the risk management office and documenting the occurrence in the client's medical record are not necessary steps in this situation.
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