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) The client tolerates a second dose of medication with no greater than 1 peripheral edema:
This does not directly indicate a therapeutic response to epinephrine for angioedema. Angioedema primarily involves swelling of deeper layers of the skin, often around the eyes and lips, and sometimes the throat, which can cause breathing difficulties. Tolerating a second dose of medication with minimal peripheral edema does not specifically address the acute respiratory effects of angioedema.
B) Respirations are unlabored:
This is the correct answer. Angioedema can cause swelling in the airways, leading to difficulty breathing. Epinephrine is used to reduce this swelling and improve airway patency. Unlabored respirations indicate that the airway is not obstructed, which means the epinephrine has successfully alleviated the swelling causing the angioedema.
C) Client reports decreased groin pain of 3 on a 1 to 10 scale:
Decreased groin pain is not relevant to the treatment of angioedema with epinephrine. Pain relief in the groin area does not indicate a therapeutic response to epinephrine, which is primarily used to address airway and anaphylactic symptoms.
D) The client's blood pressure when arising from resting position is at premedication levels:
While epinephrine can affect blood pressure, the main concern with angioedema is airway obstruction rather than blood pressure control. Normalizing blood pressure does not specifically indicate that the epinephrine has successfully treated the angioedema and improved the client's respiratory status.
Correct Answer is A
Explanation
A) Headache:
Clients with obstructive sleep apnea often experience morning headaches due to the intermittent hypoxia and hypercapnia that occur during episodes of apnea. These headaches are typically described as dull and diffuse and may improve throughout the day.
B) Nausea:
While gastrointestinal symptoms such as nausea can occur in some individuals with sleep apnea, it is not a typical or specific finding associated with this condition. Nausea may result from other causes, such as medication side effects or underlying gastrointestinal issues, rather than directly from obstructive sleep apnea.
C) Hypotension:
Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension. The recurrent episodes of hypoxemia and sympathetic nervous system activation during apneic episodes can lead to systemic hypertension over time.
D) Constipation:
Constipation is not a typical finding associated with obstructive sleep apnea. While sleep apnea may contribute to fatigue and alterations in gastrointestinal motility in some individuals, constipation is not a direct consequence of this sleep disorder.
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