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 A
Explanation
A full liquid diet includes all foods that are liquid or will turn to liquid at room temperature or melt at body temperature.
It gives you more nutrition than a clear liquid diet.
Plain yogurt is a food that can be included in a full-liquid diet.
Choice B is not the answer because oatmeal is not part of a full-liquid diet.
Choice C is not the answer because applesauce is not part of a full-liquid diet.
Choice D is not the answer because scrambled eggs are not part of a full-liquid diet.
Correct Answer is C
Explanation
A.When mixing insulins, you should draw the short-acting insulin into the syringe first. This is done after injecting air into both vials (first into intermediate-acting, then into short-acting). Drawing intermediate-acting insulin first can contaminate the short-acting insulin vial with the longer-acting solution, which could alter the effectiveness of future doses.
B.Although this step is required when mixing insulins, it is not the first step. The nurse should first inject air into both vials to maintain vial pressure.
C.The nurse should inject air into the intermediate-acting insulin vial first because it helps prevent contamination and maintains the correct pressure within the vial. Intermediate-acting insulin, typically NPH (Neutral Protamine Hagedorn), is cloudy, and air injection into the vial allows for easy withdrawal later on without disrupting the order of mixing.
D.Injecting air into the short-acting insulin vial is necessary but should be done after injecting air into the intermediate-acting vial. By injecting air into both vials first, the nurse prevents a vacuum effect, which can make it difficult to draw up the insulin. After injecting air, the nurse can draw the short-acting insulin into the syringe before moving to the intermediate-acting insulin. This order minimizes the risk of contamination.
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