When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?
Tie the restraints to the side rail.
Remove the restraints every 3 hr.
Remove one restraint at a time.
Secure restraints with a square knot.
The Correct Answer is C
When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should first auscultate the client’s bowel sounds.
This will provide important information about the client’s gastrointestinal function and can help determine the cause of the client’s symptoms.
Choice A is wrong because while offering pain medication may provide temporary relief, it does not address the underlying cause of the client’s symptoms.
Choice C is wrong because palpating the abdomen before auscultating bowel sounds can alter the bowel sounds and make it more difficult to accurately assess the client’s condition.
Choice D is wrong because administering an antiemetic may provide temporary relief from nausea and vomiting, but it does not address the underlying cause of the client’s symptoms.
Correct Answer is B
Explanation
This statement indicates that the nurse should take steps to ensure effective communication with the client by recommending an interpreter who is the same gender as the client.
This can help to facilitate understanding and comfort during the informed consent process.
Choice A is wrong because nodding alone is not sufficient to indicate understanding.
Choice C is wrong because using medical terminology can be confusing and may not facilitate understanding.
Choice D is wrong because questions should be addressed directly to the client, with the interpreter facilitating communication.
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