A nurse is providing teaching to assistive personnel 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 hr.
Allow 1 fingerbreadth between the restraint and the client's wrists.
The Correct Answer is C
Restraints should be removed every two hours to assess skin integrity under the restraints and distal circulation
A. A square knot may be difficult to release in the case of an emergency
B. Restraints should be attached to movable parts of the bed to avoid injury during pulling.
D. Allow two fingerbreadths between the restraint and the wrist
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client with active bleeding from a puncture wound in the groin is the highest priority because of the risk of severe blood loss, which can lead to hypovolemic shock. The nurse should quickly apply pressure to the wound, assess the extent of the bleeding, and prepare for emergency interventions.
B Active bleeding is part of crculation in the ABCs that comes after airway and breathing
C. Client could be having a kidney stone which is not a priority
D.These symptoms could indicate a pulmonary embolism or heart attack, but they may not be as immediately life-threatening as active bleeding.
Correct Answer is C
Explanation
the nurse should respect the client’s autonomy and wishes and inform of the provider
A. informed consent is used to accept treatment and not vice versa.
B. the nurse should not apply any form of pressure to make the client accept treatment.
D. The nurse should be empathetic. Being sympathetic is unprofessional
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