A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?

The nurse can insert one finger between the client's wrist and the restraint.

The padding of the restraints is against the client's bony prominences.

The AP ties the straps of the restraints in a double knot.

The AP ties the restraints to the side rails

Answer and Explanation

The Correct Answer is B

Answer: B. The padding of the restraints is against the client's bony prominences.

A. The nurse can insert one finger between the client's wrist and the restraint.
The proper guideline is that the nurse should be able to insert two fingers between the client's wrist and the restraint. This ensures the restraint is snug but not too tight, which helps prevent impaired circulation and skin breakdown.

B. The padding of the restraints is against the client's bony prominences.
This is the correct practice. The padding of the restraints should always be applied to protect the client’s skin and prevent injury, particularly over bony prominences where the risk of pressure sores or skin breakdown is higher.

C. The AP ties the straps of the restraints in a double knot.
A double knot should not be used because it can make it difficult to quickly release the restraint in an emergency. A quick-release knot should always be used to ensure the restraint can be removed easily and promptly if needed.

D. The AP ties the restraints to the side rails.
Restraints should never be tied to movable parts like side rails, as raising or lowering the side rails could cause injury. Restraints should be secured to a part of the bed frame that does not move to prevent harm to the client.

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Correct Answer is B

Explanation

A) Hydrochlorothiazide: Hydrochlorothiazide is a thiazide diuretic that promotes sodium and water excretion, leading to decreased blood volume and decreased potassium excretion. While it can cause hypokalemia due to increased potassium excretion, it does not typically lead to hyperkalemia.

B) Spironolactone: Spironolactone is a potassium-sparing diuretic that inhibits aldosterone, leading to decreased sodium reabsorption and increased potassium retention. This mechanism of action can predispose clients to hyperkalemia due to potassium retention. Additionally, spironolactone can cause hyponatremia by promoting the excretion of sodium and water. Therefore, clients receiving spironolactone are at risk for both hyperkalemia and hyponatremia.

C) Furosemide: Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle, promoting sodium, chloride, potassium, and water excretion. While it can cause hypokalemia due to increased potassium excretion, it does not typically lead to hyperkalemia.

D) Metolazone: Metolazone is a thiazide-like diuretic that acts similarly to hydrochlorothiazide by promoting sodium and water excretion. Like hydrochlorothiazide, it can cause hypokalemia due to increased potassium excretion but does not typically lead to hyperkalemia.

A. Disenfranchised grief B. Anticipatory grief C. Prolonged grief D. Uncomplicated grief

Correct Answer is D

Explanation

A) Disenfranchised grief:
Disenfranchised grief occurs when a person's loss is not socially recognized or supported, such as the death of a pet or an ex-spouse. The client's situation does not indicate disenfranchised grief.

B) Anticipatory grief:
Anticipatory grief happens before an impending loss, such as when a loved one is terminally ill. The client is grieving after the loss, not before it.

C) Prolonged grief:
Prolonged grief, also known as complicated grief, involves intense, persistent, and disabling grief symptoms that interfere with normal functioning. The client’s decreasing grief and positive outlook indicate that they are not experiencing prolonged grief.

D) Uncomplicated grief:
Uncomplicated grief, also known as normal grief, is the natural response to loss. It includes a range of emotions and reactions that typically diminish over time as the individual adapts to the loss. The client’s decreasing grief severity and forward-looking attitude towards spending time with their grandchildren are characteristic of uncomplicated grief.

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A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?

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