A newly licensed nurse applying prescribed wrist restraints on client. Which of the following actions should the nurse take?

Ensure four fingers fit under the restraints to prevent constriction.

Secure the restraints to the lowest bar of the side rail.

Secure the restraints using a quick-release tie.

Anticipate removing the restraints every 4 hr.

Answer and Explanation

The Correct Answer is C

A) Ensure four fingers fit under the restraints to prevent constriction: While it is important to ensure that restraints are not too tight, the general recommendation is to allow enough room for two fingers, not four. The primary goal is to prevent impaired circulation and nerve damage while also ensuring that the restraint is secure enough to prevent the patient from causing harm to themselves or others. Four fingers may be too loose and could lead to unnecessary movement.

B) Secure the restraints to the lowest bar of the side rail: Restraints should never be secured to a side rail, as the side rails may move and cause the restraint to become tight, which could lead to injury. Restraints should be tied to a fixed part of the bed frame to prevent them from becoming loose or causing undue pressure. Securing to side rails can increase the risk of harm.

C) Secure the restraints using a quick-release tie: This is the correct action. The nurse should always use a quick-release tie to ensure that the restraints can be removed immediately if needed. Quick-release ties allow for rapid removal in case of emergency, reducing the risk of injury or distress to the patient. This ensures safety while still maintaining control over the restraint application.

D) Anticipate removing the restraints every 4 hr: While restraints should be removed periodically to check the skin, circulation, and comfort of the patient, the time frame for removal varies depending on the patient's condition and the facility's protocol. Restraints should be removed more frequently than every 4 hours, if possible, to ensure the patient’s safety and comfort. The nurse should follow the facility's specific protocol for restraint monitoring and removal.

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Correct Answer is A

Explanation

A) Activate the fire alarm: The nurse's priority in the event of a fire is to activate the fire alarm immediately. This alerts others in the building, including staff and emergency responders, to the potential danger. It initiates the necessary protocol to ensure the safety of all individuals in the area and enables timely evacuation if needed. Ensuring that others are aware of the fire risk is the first critical step in managing the situation effectively.

B) Move any clients in the immediate vicinity: While moving clients away from the immediate danger is important, it should come after the alarm has been activated. The fire alarm alerts everyone to evacuate or take necessary precautions, allowing the nurse and other staff to focus on evacuation or safety measures. The priority is to ensure that everyone is aware of the potential fire hazard and follows the evacuation procedures.

C) Close the fire doors on the unit: Closing fire doors is part of fire containment, but it should occur after the alarm has been activated and the fire response plan is in motion. Fire doors are designed to limit the spread of fire, but the initial priority is to alert others to the fire, activate the alarm, and ensure everyone is aware of the emergency situation.

D) Use a fire extinguisher to put out the fire: Using a fire extinguisher is appropriate if the fire is small and manageable, but activating the fire alarm is still the first priority. In cases of small fires, if safe to do so, the nurse can attempt to put it out. However, the primary focus should be on alerting everyone in the facility to the danger so that emergency protocols can be followed.

A. History of smoking B. Obesity C. Genetics D. History of hypertension

Correct Answer is C

Explanation

A) History of smoking: Smoking is a modifiable risk factor, meaning it can be reduced or eliminated through lifestyle changes. While smoking significantly increases the risk of stroke, it is not a nonmodifiable risk factor. Educating clients about the benefits of quitting smoking is important to reduce stroke risk.

B) Obesity: Obesity is also a modifiable risk factor. Lifestyle changes such as diet and exercise can help manage and reduce obesity, which in turn reduces the risk of stroke. While obesity increases the likelihood of stroke, it is not considered nonmodifiable.

C) Genetics: Genetics are a nonmodifiable risk factor. A family history of stroke or certain genetic predispositions can increase the risk of stroke. These genetic factors cannot be altered, which is why they should be included in the discussion about stroke risk factors.

D) History of hypertension: Hypertension, or high blood pressure, is a significant risk factor for stroke, but it is modifiable through medication, diet, and lifestyle changes. It is not a nonmodifiable risk factor. Managing blood pressure through appropriate treatment and lifestyle changes can reduce the risk of stroke.

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