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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitor an IV infusion rate on an established schedule: This task is appropriate for a UAP because it involves observation and reporting rather than clinical decision-making. The UAP can ensure the IV is running at the prescribed rate and alert the nurse if any deviations occur.
B. Titrate oxygen to the prescribed parameters: Adjusting oxygen requires clinical judgment and assessment of respiratory status, including oxygen saturation and signs of hypoxia. This is a nursing responsibility and cannot be delegated to a UAP.
C. Insert a urinary catheter for an uncomplicated client: Catheter insertion is a sterile procedure that requires nursing knowledge and skill. Delegation to a UAP is not permitted due to the risk of infection and need for proper technique.
D. Procure platelet products from the blood bank: Obtaining blood products involves verification of patient identifiers, blood type, and compatibility, which are nursing responsibilities. This task requires clinical accountability and cannot be delegated to a UAP.
Correct Answer is C
Explanation
A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.
B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.
C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.
D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.
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