When using wrist restraints, which of these statements is correct?

Apply them safely and secure to the bed rails.

Use to protect elderly patients from pulling out tubes and lines as soon as you place them.

Apply them to clients who have a history of violence or a previous fall for everyone’s protection.

Use them only as a last resort after attempting alternatives and get an order to do so.

Answer and Explanation

The Correct Answer is D

Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.

Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.

This prevents the person from getting entangled or injured by the restraints.

Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.

Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.

Normal ranges for restraints are:

Check the person at least every 15 minutes
Remove restraints and meet basic needs at least every 2 hours
Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

This is because it shows a normal pH, pCO2, HCO3 and pO2, indicating that the treatment has been effective in restoring normal gas exchange and acid- base balance.

Choice A is wrong because it shows a low pH, high pCO2 and high HCO3, indicating a mixed respiratory and metabolic acidosis.

Choice B is wrong because it shows a low pH, high pCO2 and low HCO3, indicating a combined respiratory and metabolic acidosis.

Choice D is wrong because it shows a high pH, low pCO2 and low HCO3, indicating a mixed respiratory and metabolic alkalosis.

The normal ranges for arterial blood gas (ABG) are:

pH: 7.35 – 7.45
pO2: 10 – 14 kPa or 75 – 105 mmHg
pCO2: 4.5 – 6 kPa or 34 – 45 mmHg

A. It is a legal record of accountability for protection of the client and the nurse. B. It supports confidentiality and privacy and should never. C. It provides continuous reference for all care providers to refer to. D. it provides a framework for clients rights and records if they are violated.

Correct Answer is A

Explanation

It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.

Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.

Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.

Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.

View Question and Answer

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

When using wrist restraints, which of these statements is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with severe bronchial pneumonia has been receiving oxygen, respiratory treatments, antibiotics, and intravenous fluids. Which arterial blood gas result would indicate that the treatment has been effective?

Correct Answer is C

Explanation

The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?

Correct Answer is A

Explanation

Which prescription written by a health care provider for an eye drop medication is written correctly?

The client has diabetes Type I, a body mass index (BMI) of 17 and poor skin turgor. How should the nurse plan to administer the prescribed. Humulin R 7 units subcutaneously?

The nurse is educating a client with insomnia how to promote better sleep. Which interventions should she include for this client? (Select all that apply).

A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?

A client asks a nurse, “Why do I have to remove my nail polish in order for my pulse oximetry to be monitored?” Which is the best response by the nurse?

The nurse observes the unlicensed assistive personnel (UAP) obtain vital signs on four adult clients. For which client should the nurse intervene to redirect to use of proper method?

A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease. What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?