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 ["A","C","D","E"]

Explanation

Answer: A, C, D, E

Rationale:

A) Yoga: Yoga is an effective nonpharmacological therapy that combines physical postures, breathing exercises, and meditation, which can help reduce stress, improve flexibility, and enhance mental focus.

B) Electromagnetic therapy: Electromagnetic therapy is typically used for pain management or to promote wound healing rather than stress reduction. It is not commonly included in stress management techniques.

C) Meditation: Meditation focuses on mindful breathing and awareness, which can significantly reduce stress by calming the mind and improving emotional resilience. It’s widely used to help manage stress and anxiety.

D) Acupuncture: Acupuncture involves the insertion of needles at specific body points and is believed to release endorphins and balance energy flow, which can reduce stress and promote relaxation.

E) Biofeedback: Biofeedback teaches clients to control physiological responses like heart rate and muscle tension, helping them manage stress and anxiety effectively through self-regulation techniques.

A. Administer 200 mL of formula during the initial infusion B. Give the initial feeding over 15 min. C. Reconstitute the formula with tap water D. Discard unused formula after 8 hr.

Correct Answer is D

Explanation

A) Administer 200 mL of formula during the initial infusion:
The initial infusion rate for continuous enteral feeding is typically started at a slower rate, often lower than 200 mL, to assess the client's tolerance and prevent complications such as aspiration or dumping syndrome.

B) Give the initial feeding over 15 min:
Continuous enteral feeding is administered slowly over an extended period, usually 24 hours, to ensure gradual delivery of nutrients and minimize the risk of complications such as aspiration or gastrointestinal intolerance. Giving the initial feeding over 15 minutes is too rapid and can lead to adverse events.

C) Reconstitute the formula with tap water:
Reconstituting enteral formula with tap water is not recommended due to the potential risk of contamination with bacteria or other pathogens. It's essential to use sterile water or water that has been specifically purified for enteral feeding to minimize the risk of infection.

D) Discard unused formula after 8 hr:
Unused formula should be discarded after 4 hours, not 8 hours, to reduce the risk of bacterial contamination and ensure the integrity of the enteral nutrition. This practice aligns with guidelines for safe enteral feeding administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a class about nonpharmacological therapies to decrease stress. The nurse should include which of the following therapies? (Select All that Apply)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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