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 D

Explanation

Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.
This is because if a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse.
Choice A is wrong because the count total of the controlled substance should be verified before removing the amount needed, not after.
Choice B is wrong because the wasted portion of the controlled substance should not be placed in the sharps container.
It should be disposed of according to facility/agency policy.
Choice C is wrong because any discrepancy in the count total of the controlled substance should be reported immediately, not after administration 1.

A. Eat a light carbohydrate snack before bedtime. B. Take a 30-min nap daily. C. Drink a cup of hot cocoa before bedtime. D. Exercise 1 hr before bedtime.

Correct Answer is A

Explanation

Eating a light carbohydrate snack before bedtime can help promote sleep by increasing the level of tryptophan in the brain.
Choice B is wrong because taking a 30-min nap daily can disrupt nighttime sleep and worsen insomnia.
Choice C is wrong because drinking a cup of hot cocoa before bedtime can interfere with sleep due to its caffeine content.
Choice D is wrong because exercising 1 hr before bedtime can increase alertness and make it more difficult to fall asleep.

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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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