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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- While understanding the frequency that a problem occurs can provide context to its significance and potential impact, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency alone does not ensure that the evidence collected will be directly applicable to the current situation.
B) Incorrect- Personal values are subjective and may influence an individual's perspective, but they are not the primary consideration when gathering evidence for evidence-based decision- making. Evidence-based practice aims to rely on objective and scientifically validated information rather than personal values, which can vary greatly among individuals.
C) Correct- The most important consideration when gathering evidence is its relevance to the specific situation at hand. Evidence must directly address the problem and clinical question, ensuring that the information collected is applicable, appropriate, and reliable for guiding decision-making in the current context.
D) Incorrect- While past experiences can offer insights, they are not the most important consideration for evidence-based decision-making. Relying solely on past experiences may not account for new developments, changing guidelines, or unique aspects of the current situation that were not present in previous encounters.
Correct Answer is B
Explanation
Gravida: The client has been pregnant five times: three times she gave birth to term babies, once she gave birth to preterm twins, and once she had a spontaneous abortion.
Term births: She has given birth three times: at 38 weeks, 41 weeks, and 35 weeks (twins). These are all considered term births. Term pregnancies are 37 weeks and beyond. So, the number of term births is 2.
Preterm births: She had one birth at 35 weeks, which is considered preterm. So, the number of preterm births is 1.
Abortions: She had one spontaneous abortion at 10 weeks' gestation. So, the number of abortions is 1.
Living children: All of her children are alive and well. So, the number of living children is 4.
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