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
The correct answer is B.
Choice A reason: Using a stiff toothbrush to clean the client’s teeth is not recommended. A stiff toothbrush can cause damage to the gums and teeth, especially in clients who may have sensitive oral tissues due to medications or medical treatments.
Choice B reason: Turning the client on his side before starting oral care is the most appropriate action. This is to prevent aspiration, especially in immobile clients who may have difficulty swallowing or clearing their throat.
Choice C reason: Using the thumb and index finger to keep the client’s mouth open is not recommended. This could be uncomfortable or even harmful for the client. Instead, a padded tongue blade could be used if necessary, but only with extreme caution and the client’s comfort in mind.
Choice D reason: Applying petroleum jelly to the client’s lips after oral care is also a good practice. This helps to prevent dryness and cracking of the lips, which can be a common problem for hospitalized patients, especially those who are dehydrated or receiving oxygen therapy. However, when compared to choice B, it is not as critical in terms of immediate safety concerns.
Correct Answer is ["4"]
Explanation
To calculate the correct dose in milliliters (mL), you can use the formula: Desired Dose (in mg) = Available Dose (in mg/mL) * Volume (in mL)
Desired Dose (in mg) = 40 mg Available Dose (in mg/mL) = 10 mg/1 mL Now, plug these values into the formula: Volume (in mL) = 40 mg / 10 mg/1 mL Volume (in mL) = 4 mL.
The nurse should administer 4 mL of furosemide per dose.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.