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.

Ensure that the knot can be quickly released.

Tie the knot with a double turn or square knot.

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

Answer and Explanation

The Correct Answer is B

A.   Restraints should be secure but not too tight to prevent injury or impaired circulation.
B.   Ensuring the knot can be quickly released is critical for the client's safety in case of emergency.
C.   A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk.
D.   Restraints should never be tied to side rails as this can cause injury if the rails are moved.

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Correct Answer is B

Explanation

A. Reconciling medication dosages is important but comes after verifying the accuracy of the prescriptions.
B. Comparing admission prescriptions with the client's previous medication list ensures continuity of care and prevents omissions or duplications.
C. Determining generic versus brand name medications can be addressed later after ensuring medication accuracy.
D. Client teaching is important but should follow the verification of the client's current medications.

A. Advise the UAP to stop providing care so the nurse can assess the client's condition. B. Explain to the UAP that changes in a client's condition should be reported immediately. C. Determine why the UAP did not notify the nurse of the change in the client's condition. D. Ask the UAP to position the client so the oral medications can be administered.

Correct Answer is A

Explanation

A. The priority is to immediately intervene in the care being provided by the UAP and assess the client's condition to ensure prompt intervention if necessary.

B. While educating the UAP is important, immediate assessment and intervention for the client take precedence.
C. Investigating the reason for the UAP's actions can wait until after the client's condition has been assessed and stabilized.
D. Administering oral medications can wait until after the client's condition has been assessed and stabilized.

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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

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Explanation

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