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) Delayed gastric emptying: This condition refers to a slowdown in the movement of food from the stomach to the small intestine, often leading to symptoms like nausea, vomiting, bloating, and early satiety. It is not related to breath sounds and would not be detected through auscultation of the lungs.

B) Atelectasis: This condition involves the collapse or closure of lung tissue, resulting in reduced or absent gas exchange. It commonly occurs in patients who are immobile or on bedrest for extended periods, such as the client with a lacerated spleen. Decreased breath sounds in the lower lobes of the lungs are a typical finding in atelectasis, as the collapsed or partially collapsed alveoli do not allow air to move through them, leading to diminished or absent breath sounds in the affected areas.

C) An upper respiratory infection: This condition involves infections in the nose, throat, and airways and typically presents with symptoms like cough, nasal congestion, sore throat, and sometimes fever. It can affect breath sounds, but it more commonly causes wheezing, crackles, or rhonchi rather than isolated decreased breath sounds in the lower lobes.

D) Pulmonary edema: This condition is characterized by the accumulation of fluid in the lungs, often due to heart failure or acute lung injury. Auscultation findings typically include crackles or rales, particularly in the lower lung fields, but not necessarily decreased breath sounds unless there is a significant consolidation or fluid volume.

A. Palliative care is limited to clients who are in a healthcare facility. B. The goal of palliative care is to cure an acute illness for a client. C. Palliative care is restricted to clients who are terminally ill D. Palliative care can be provided to a client who is receiving a curative treatment

Correct Answer is D

Explanation

A) Palliative care is limited to clients who are in a healthcare facility: Palliative care can be provided in various settings, including hospitals, hospices, long-term care facilities, and even in the client's home. It is not limited to clients who are in a healthcare facility.

B) The goal of palliative care is to cure an acute illness for a client: Palliative care focuses on providing relief from the symptoms and stress of a serious illness, rather than curing the illness itself. The primary goal is to improve the quality of life for both the client and their family, focusing on physical, psychosocial, and spiritual aspects of care.

C) Palliative care is restricted to clients who are terminally ill: While palliative care is often associated with end-of-life care for clients with terminal illnesses, it is not limited to this population. Palliative care can be provided at any stage of a serious illness, from diagnosis through treatment, survivorship, or end-of-life care.

D) Palliative care can be provided to a client who is receiving a curative treatment: This is the correct statement. Palliative care can be integrated with curative treatment for clients with serious illnesses. It focuses on managing symptoms, providing emotional support, and improving the overall quality of life, regardless of whether the client is receiving treatment aimed at curing their illness.

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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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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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