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

Tie the knot with a double turn or square knot.

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.

Answer and Explanation

The Correct Answer is D

Choice A: A double turn or square knot is not recommended because it is not a quick-release knot, which is necessary for patient safety in case of an emergency

Choice B: While restraints need to be secure, they should not be snug against the client's wrists. There should be enough space to fit two fingers between the restraint and the wrist to prevent circulation issues.

Choice C: Ties should not be secured to side rails as this can cause injury if the rails are moved. Instead, they should be attached to the movable part of the bed frame.

Choice D: This is the correct action. A half-bow knot is a type of quick-release knot, which is essential for the safety and quick release of the patient if needed

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Correct Answer is C

Explanation

A) Incorrect- Pupillary response is not relevant to the assessment of mesalamine's effectiveness.
Pupillary response is often assessed in neurological or ophthalmic evaluations and is not a direct measure of gastrointestinal function or the response to mesalamine therapy.
B) Incorrect- Peripheral pulses are not directly affected by mesalamine therapy, and monitoring them would not provide insight into the medication's effectiveness. Peripheral pulses are typically assessed to evaluate circulatory status and are not specific to the evaluation of gastrointestinal conditions.
C) Correct- Mesalamine is a medication commonly used to treat inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. It helps to reduce inflammation in the gastrointestinal tract. Monitoring bowel patterns is important to assess the effectiveness of mesalamine in managing the symptoms of these conditions.
D) Incorrect- Oxygen saturation is a measure of the amount of oxygen in the blood and is used to assess respiratory function. While oxygen saturation is important for overall patient assessment, it is not directly related to mesalamine's effectiveness in treating inflammatory bowel disease.

A. Periodic nausea and vomiting B. Decreased deep tendon reﬂexes C. Platelet count 135,000/mm3 or 135 x 10^9/L D. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L

Correct Answer is D

Explanation

A high blood urea nitrogen (BUN) level indicates impaired renal function, which can be caused by dehydration, infection, or nephrotoxic drugs. Chemotherapy can damage the kidneys and increase the risk of renal failure. The PN should report this finding to the charge nurse, as it may require ﬂuid replacement, dose adjustment, or discontinuation of the chemotherapy.

The other options are not correct because:

Periodic nausea and vomiting are common side eﬀects of chemotherapy that can be managed with antiemetics, hydration, and dietary modifications. They are not as urgent as a high BUN level.
Decreased deep tendon reﬂexes may indicate hypocalcemia, hypomagnesemia, or peripheral neuropathy, which can be caused by chemotherapy or other factors. They are not as urgent as a high BUN level.
A platelet count of 135,000/mm3 or 135 x 10^9/L is slightly below the normal range, but not significantly low. Chemotherapy can cause thrombocytopenia, which increases the risk of bleeding. The PN should monitor the client for signs of bleeding, but this finding is not as urgent as a high BUN level.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving mesalamine 800 mg by mouth three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

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