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 ["9"]

Explanation

To calculate the new infusion rate in mL/hour for a prescription of 900 units/hour, one must first determine the concentration of the Heparin Sodium solution. The original concentration is 25,000 units in 250 mL, which means there are 100 units per mL. To deliver 900 units/hour, the nurse should program the infusion pump to deliver 9 mL/hour. This is because 900 units divided by the concentration of 100 units/mL equals 9 mL.

A. IV administration of benztropine. B. PO administration of divalproex. C. PO administration of lorazepam. D. IV administration of isotonic crystalloid fluid.

Correct Answer is A

Explanation

A. Benztropine is an anticholinergic medication that is effective in rapidly treating acute dystonic reactions, including laryngeal spasms, which can be life-threatening. It works by counteracting the imbalance of neurotransmitters caused by certain medications.
B. Divalproex is used for mood stabilization and seizure control but is not effective in treating acute dystonic reactions.
C. Lorazepam, while useful for anxiety and agitation, is not the first-line treatment for dystonic reactions and does not address the underlying neurotransmitter imbalance.
D. Isotonic crystalloid fluids are important for hydration but do not treat the cause of the dystonic reaction.

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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 client is receiving "Heparin Sodium 25,000 Units in 250 mL 5% Dextrose" IV at 7 mL/hour. The healthcare provider changes the prescription to 900 units/hour. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only.)

Correct Answer is ["9"]

Explanation

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is A

Explanation

Exhibits Drag from the word choices to complete the sentence The client demonstrates effective epidural anesthesia by and ,

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