Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Ensure that the restraints are snug against the client's wrists.

Move the ties so the restraints are secured to the side rails.

Ensure that the knot can be quickly released.

Tie the knot with a double turn or square knot.

Answer and Explanation

The Correct Answer is C

A. Ensure that the restraints are snug against the client's wrists: Restraints should be snug enough to prevent injury but not so tight as to impair circulation. However, this does not address the safety concern related to the type of knot used.

B. Move the ties so the restraints are secured to the side rails: Restraints should never be tied to the side rails because this can cause injury if the rail moves or the client attempts to climb over it.

C. Ensure that the knot can be quickly released: Using a quick-release knot, such as a half bow or slip knot, is essential to ensure the nurse can rapidly remove the restraints in an emergency, such as sudden respiratory distress or circulatory compromise.

D. Tie the knot with a double turn or square knot: Square knots are secure but not quick to release. In contrast, safety guidelines recommend quick-release knots for client restraints to allow for prompt intervention.

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Correct Answer is B

Explanation

A. Before going to bed: Bedtime glucose checks may be recommended for some clients, especially those on insulin, but this timing is individualized. It is not universally required for every client with diabetes.

B. During acute illness: Any client with diabetes, regardless of age or type, should monitor glucose closely during acute illness. Illness can cause stress-induced hyperglycemia or unpredictable fluctuations, requiring more frequent testing to guide management.

C. Prior to exercising: Checking glucose before exercise is important for clients at risk of hypoglycemia, especially those using insulin or certain oral agents. However, this is not necessary for all clients, particularly those with type 2 diabetes controlled by diet alone.

D. Immediately after meals: Postprandial monitoring is useful in some cases to evaluate mealtime insulin effectiveness or dietary impact, but it is not universally recommended for every diabetic client. Its use depends on individualized treatment plans.

A. Pain level presently 3 on a 0 to 10 scale B. The client reports feeling "sleepy." C. Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer. D. New mild cough noted. E. Repositions in bed with minimal assistance. F. Attempted to get up to the chair, but experienced dizziness with standing.

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

Explanation

Rationale for correct choices:

• Pain level presently 3 on a 0 to 10 scale: A reduction in pain from 8/10 to 3/10 indicates that the morphine is effectively alleviating the client’s pain. Effective analgesia allows for improved comfort, participation in breathing exercises, and reduced stress response.

• Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer: Increased inspiratory volume demonstrates improved lung expansion, indicating that pain control is facilitating better respiratory effort. This is especially important to prevent atelectasis and maintain adequate oxygenation after rib fractures.

• Repositions in bed with minimal assistance: Ability to move with less assistance reflects improved comfort and mobility due to effective pain management. This shows the therapeutic effect of analgesia in enabling functional activity without excessive pain.

Rationale for incorrect choices:

• Client reports feeling "sleepy": Sleepiness is a common side effect of morphine, reflecting central nervous system depression rather than a therapeutic effect of pain relief. While mild sedation can accompany effective analgesia, it does not directly indicate improvement in the underlying condition.

• New mild cough noted: The appearance of a new cough is not a direct indicator of therapeutic pain relief. It may reflect airway irritation, increased secretions, or a response to deeper breathing, but it is not a measure of analgesic effectiveness.

• Attempted to get up to the chair, but experienced dizziness with standing: Dizziness indicates a side effect of the opioid (orthostatic hypotension or sedation), not a therapeutic response. This finding requires monitoring and safety interventions.

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Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Correct Answer is B

Explanation

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

Explanation

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