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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) 41-year-old with hypernatremia:
Hypernatremia refers to elevated levels of sodium in the blood. While hypernatremia can lead to dehydration and electrolyte imbalances, it does not directly correlate with an increased risk of hypomagnesemia.
B) 72-year-old with chronic alcoholism:
Chronic alcoholism is a significant risk factor for hypomagnesemia. Alcohol abuse can lead to poor dietary intake of magnesium, increased renal excretion of magnesium, and impaired absorption of magnesium in the gastrointestinal tract, all contributing to magnesium deficiency.
C) 79-year-old with bone cancer:
Bone cancer does not inherently increase the risk of hypomagnesemia. However, depending on the treatment modalities and disease progression, the client may be at risk for other electrolyte imbalances or complications associated with bone cancer.
D) 46-year-old with respiratory acidosis:
Respiratory acidosis refers to an acid-base imbalance characterized by elevated levels of carbon dioxide in the blood due to impaired ventilation. While respiratory acidosis can lead to electrolyte imbalances, particularly potassium imbalances, it is not directly linked to hypomagnesemia.
Correct Answer is D
Explanation
A) Contact: While contact precautions are important for preventing the transmission of infections, they primarily apply to clients with known or suspected infections that can spread through direct or indirect contact with the client or their environment. Protective isolation goes beyond contact precautions and involves comprehensive measures to protect immunocompromised clients from all potential sources of infection.
B) Airborne: Airborne precautions are necessary for clients with infections that spread through the airborne route, such as tuberculosis or measles. While respiratory infections can pose a significant risk to immunocompromised clients, the focus of care for clients after hematopoietic stem-cell transplant is on preventing all types of infections, not just airborne ones.
C) Droplet: Droplet precautions are used for infections transmitted through respiratory droplets expelled when a person coughs, sneezes, or talks, such as influenza or pertussis. While respiratory infections are a concern for immunocompromised clients, the broader approach of protective isolation is more appropriate for clients after hematopoietic stem-cell transplant, as it encompasses all potential routes of infection transmission, not just droplet spread.
D) Protective: Clients who have undergone allogeneic hematopoietic stem-cell transplant are profoundly immunocompromised due to the destruction of their immune system and are highly susceptible to infections. Protective isolation, also known as reverse isolation, is necessary to minimize the risk of infection in these clients. This includes implementing strict infection control measures such as wearing gowns, gloves, masks, and sometimes goggles to prevent exposure to pathogens. Additionally, maintaining a clean environment and limiting visitors and healthcare personnel who may carry infectious agents are essential components of protective isolation.
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