A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.
Which of the following information should the nurse include? (Select all that apply.)
Family members who smoke must be at least 10 ft from the client when oxygen is in use.
Nail polish remover or hair spray should not be used near a client who is receiving oxygen.
A "No Smoking" sign should be placed on the front door.
Cotton bedding and clothing should be replaced with items made from wool.
A fire extinguisher should be readily available in the home.
Correct Answer : D
Choice A rationale:
Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.
Choice B rationale:
Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.
Choice C rationale:
Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.
Choice D rationale:
Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice a. Retie the restraint straps with a slipknot.
Choice A rationale:
The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.
Choice B rationale:
It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.
Choice C rationale:
Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.
Choice D rationale:
The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.
Correct Answer is D
Explanation
Choice A rationale:
Wearing a mask when entering the client's room is not specifically required for contact precautions. Masks are primarily used for airborne precautions or when caring for patients with respiratory infections spread through droplets.
Choice B rationale:
Removing potted plants from the room may be a good practice for infection control, but it is not a specific action mandated by contact precautions. Contact precautions primarily focus on preventing the transmission of infections through direct or indirect contact with the patient or their environment.
Choice C rationale:
Allowing the client to leave the room every 2 hours is not a recommended practice for contact precautions. Patients under contact precautions should ideally stay in their rooms to prevent the spread of infections to others in the healthcare facility.
Choice D rationale:
When caring for a client under contact precautions, it is essential to dedicate equipment and supplies for their use exclusively. This helps prevent the spread of infections to other patients or healthcare workers by avoiding the contamination of shared items.
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