A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

Secure the client's restraints with a square knot

Attach the restraints to the fixed portion of the frame of the client's bed

Remove the client's restraints every 2 hours

Allow 1 fingerbreadth between the restraint and the client's wrists

Answer and Explanation

The Correct Answer is B

A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.

B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.

C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.

D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.

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Correct Answer is B

Explanation

Choice A reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac problem, which is a serious condition. However, this client is not the highest priority, as the symptoms are not life-threatening at the moment.

Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority, as this client is at risk of hemorrhage, shock, and infection. The nurse should apply direct pressure to the wound, elevate the leg, and monitor the vital signs.

Choice C reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction, which is a potential emergency. However, this client is not the highest priority, as the symptoms are not severe enough to indicate anaphylaxis.

Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a kidney stone, which is a painful condition. However, this client is not the highest priority, as the symptoms are not life-threatening unless there is an obstruction or infection.

A. My durable power of attorney for health care is part of my advance directives. B. Once I sign my living will, a family member must co-sign. C. My doctor will need to provide approval for the decisions outlined in my living will. D. I will wait until I have a serious health problem to sign my advance directives.

Correct Answer is A

Explanation

Choice A reason: A durable power of attorney for health care is a type of advance directive that allows the client to designate a person who can make health care decisions for them if they become incapacitated. This is a valid statement by the client that shows an understanding of the teaching.

Choice B reason: A living will is another type of advance directive that specifies the client's wishes regarding life-sustaining treatments. A family member does not need to co-sign the living will for it to be valid. This is an incorrect statement by the client that shows a misunderstanding of the teaching.

Choice C reason: The doctor does not need to provide approval for the decisions outlined in the living will. The living will is a legal document that expresses the client's preferences and values. The doctor should respect and follow the living will as much as possible. This is an incorrect statement by the client that shows a misunderstanding of the teaching.

Choice D reason: The client should not wait until they have a serious health problem to sign their advance directives. The client should sign their advance directives when they are mentally competent and able to communicate their wishes. This is an incorrect statement by the client that shows a misunderstanding of the teaching.

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A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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