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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The nurse should use the abbreviation “BRP” for bathroom privileges.
This is a commonly accepted abbreviation in the medical field and is used to indicate that a client has permission to use the bathroom.
Choice A is not the correct answer because “SC” is not a commonly accepted abbreviation for subcutaneous.
Instead, “SQ” or “SubQ” are more commonly used.
Choice B is not the correct answer because “SS” is not a commonly accepted abbreviation for sliding scale.
Instead, “Sliding Scale” should be written out in full to avoid confusion.
Choice D is not the correct answer because “OJ” is not a commonly accepted medical abbreviation for orange juice.
Instead, “orange juice” should be written out in full to avoid confusion.

A. Hold the syringe so that bubbles collect at the level of the plunger. B. Hold the vial with the top facing upward while injecting air into the vial. C. Inject air into the vial with the eye of the needle immersed in the fluid. D. Hold the syringe at a 45° angle to verify dosage.

Correct Answer is B

Explanation

When preparing medication from a vial for subcutaneous injection for a client, the nurse should hold the vial with the top facing upward while injecting air into the vial.
This is because injecting air into the vial equalizes the pressure inside and makes it easier to withdraw the medication 1.
Choice A is wrong because holding the syringe so that bubbles collect at the level of the plunger is not necessary when preparing medication from a vial.
Choice C is wrong because injecting air into the vial with the eye of the needle immersed in the fluid can contaminate the medication.
Choice D is wrong because holding the syringe at a 45° angle is not necessary when verifying dosage.

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When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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