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) Reduced respiratory rate:
Acute pain typically triggers an increased respiratory rate rather than a reduced one. Pain activates the sympathetic nervous system, leading to increased respiratory effort as the body prepares to fight or flee.

B) Elevated blood pressure:
Elevated blood pressure is a common physiological response to acute pain. Pain activates the sympathetic nervous system, leading to the release of stress hormones like adrenaline, which constrict blood vessels and increase heart rate and blood pressure.

C) Constricted pupils:
Pain often causes pupil dilation rather than constriction. The body's fight-or-flight response to pain involves pupil dilation to enhance visual acuity and peripheral vision, allowing individuals to detect potential threats in their environment.

D) Decreased heart rate:
Acute pain typically results in an increased heart rate rather than a decreased one. Pain triggers the release of adrenaline, which increases heart rate as part of the body's stress response to prepare for action.

A. Prime the blood tubing with dextrose 5% in water. B. Check vital signs before transfusion C. Insert an IV with a 13-gauge needle D. Transfuse the blood product within 5 hr after removing it from refrigeration E. Check the expiration date of the blood product with a second nurse

Correct Answer is ["B","D","E"]

Explanation

A. Prime the blood tubing with dextrose 5% in water:
Priming the blood tubing with dextrose 5% in water is not appropriate for a blood transfusion. Blood tubing should be primed with normal saline, not dextrose solutions, to prevent hemolysis of the blood components.
B. Check vital signs before transfusion:
Before initiating a blood transfusion, it's essential to assess the client's vital signs, including temperature, pulse, respiratory rate, and blood pressure. Monitoring vital signs before, during, and after the transfusion helps identify any adverse reactions promptly.
C. Insert an IV with a 13-gauge needle:
Using a 13-gauge needle for IV insertion is not appropriate for a blood transfusion. Typically, a smaller gauge needle, such as 18 or 20 gauge, is used for venous access during a blood transfusion to minimize discomfort and reduce the risk of hemolysis.
D. Transfuse the blood product within 5 hr after removing it from refrigeration:
Blood products should be transfused within a specific timeframe after removal from refrigeration to minimize the risk of bacterial growth and subsequent infection. Typically, this timeframe is within 4 hours for packed red blood cells and within 24 hours for platelets. Adhering to the recommended timeframe ensures the safety and efficacy of the transfusion.
E. Check the expiration date of the blood product with a second nurse:
Verifying the expiration date of the blood product with a second nurse or healthcare provider is a crucial step to ensure patient safety and prevent the administration of expired blood products. This double-check process helps mitigate the risk of administering outdated or expired blood components.

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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 assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?

Correct Answer is B

Explanation

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

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