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. A potty chair should be brought from home to maintain the current level of toileting skills: While familiar items can offer comfort, regression in toileting is typically temporary and does not require special equipment to preserve skills.

B. Children usually resume their toileting behaviors when they leave the hospital: Hospitalization is a stressful event for preschoolers, and temporary regression in toileting is common. Reassuring parents that the child is likely to return to previous toileting behaviors once home helps reduce anxiety and supports normal developmental expectations.

C. Diapering will be provided since hospitalization is stressful to preschoolers: Diapering may be used for convenience or safety, but presenting it as necessary for all hospitalized children may cause unnecessary concern. It does not address the expected return to prior skills.

D. A retraining program will need to be initiated when the child returns home: Most children spontaneously resume previous toileting abilities without formal retraining. Only persistent regression after discharge would warrant intervention.

A. IV site without redness or swelling B. Temperature: 98.8° F (37.1° C) C. Respirations: 28 breaths/minute D. Heart rate: 92 beats/minute E. Taking shallow breaths F. Alert and oriented to person, place, time and situation G. Pain 8 on a 0 to 10 scale H. Blood pressure: 138/82 mm Hg I. Blood pressure: 138/82 mm Hg

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

Explanation

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

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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

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

Correct Answer is B

Explanation

Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

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

Explanation

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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?

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