A newly licensed nurse is applying prescribed wrist restraints on a client.
Which of the following actions should the nurse take?
Anticipate removing the restraints every 4 hr.
Ensure four fingers fit under the restraints to prevent constriction.
Secure the restraints using a quick-release tie.
Secure the restraints to the lowest bar of the side rail.
The Correct Answer is C
The correct answer is Choice C. Secure the restraints using a quick-release tie.
Choice A rationale: Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.
Choice B rationale: Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.
Choice C rationale: Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.
Choice D rationale: Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
TJC (The Joint Commission) does not provide licensure for healthcare providers. Licensing is typically issued by state regulatory bodies, and it ensures that healthcare professionals meet the minimum qualifications and standards to practice within their respective states. TJC's role is different from providing licensure.
Choice B rationale:
TJC is primarily responsible for accrediting healthcare facilities, including hospitals and clinics, to ensure that they meet specific quality and safety standards. Accreditation by TJC is a mark of quality and demonstrates that the facility complies with nationally recognized healthcare standards.
Choice C rationale:
TJC is not a for-profit organization. It is an independent, non-profit organization dedicated to improving healthcare quality and safety. It does not seek to generate profits but rather focuses on enhancing the quality of care provided to patients.
Choice D rationale:
TJC is not an organization that monitors insurance claims. Monitoring insurance claims is typically the responsibility of insurance companies and regulatory agencies. TJC's primary role is to assess and accredit healthcare facilities to promote patient safety and quality care.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Using a cell phone to request assistance from the client's room ensures timely communication and enhances patient care. Quick access to help can be vital in emergency situations, ensuring prompt and effective intervention.
Choice B rationale: Sending a personal text to a co-worker during work hours is unprofessional and can lead to distractions. It can compromise patient care and violates workplace policies on personal device usage, ensuring focus remains on patient safety and care.
Choice C rationale: Calling the client's family member per their request can violate privacy and confidentiality regulations, such as HIPAA in the US. Communication with family should go through proper channels to ensure compliance with legal and ethical standards.
Choice D rationale: Taking a photo of a client's incision site for learning purposes without proper consent and documentation breaches patient confidentiality and privacy. It could also result in legal ramifications and violates institutional policies on using personal devices for work-related tasks.
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