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 A
Explanation
This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the flowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.
The other options are not correct because:
B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.
C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not affect the oxygen delivery or uptake.
D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.
Correct Answer is B
Explanation
A. Offering 10% dextrose via nipple feeding is used for infants who are unable to feed orally or with severe hypoglycemia. This neonate is still within range hence dextrose is not incicated at this point.
B. The infant is jittery with a glucose of 40 mg/dL, which indicates mild symptomatic hypoglycemia. Initiating frequent feedings of breast milk or formula is the first action to stabilize glucose while supporting oral intake.
C. Repeating the heel stick is important for monitoring, but it does not treat the low glucose and is not the first action.
D. Assessing for hypocalcemia may be indicated later, but the priority is addressing hypoglycemia through feeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
