A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot.
Which of the following actions should the nurse take?
Retie the restraint straps with a slipknot.
Check that three fingers will fit beneath the restraints.
Retie the restraint straps to the side rails.
Remove the padding under the wrist restraints.
The Correct Answer is A
The correct answer is choice a. Retie the restraint straps with a slipknot.
Choice A rationale:
The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.
Choice B rationale:
It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.
Choice C rationale:
Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.
Choice D rationale:
The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A suffix is a word part that is added to the end of a root word to modify its meaning. For example, in the medical term "cardiologist," the suffix '-ologist' means a specialist or expert. A suffix is placed at the end of a root word or a combining form to create a specific medical term.
Choice B rationale:
A word root is the foundational part of a medical term. It contains the core meaning of the term and is not usually modified by prefixes or suffixes. For instance, in the term "cardiology," 'cardi-' is the word root, representing the heart. Word roots provide the essential meaning of the medical term.
Choice C rationale:
A prefix is a word part that is added to the beginning of a root word or a combining form to modify its meaning. Prefixes are important in medical terminology as they indicate locations, numbers, or time. For example, in the term "prehypertension," the prefix 'pre-' means before. Prefixes are added at the beginning of a word.
Choice D rationale:
A combining form is a word root combined with a vowel (usually 'o') that can be joined with other word parts to create a medical term. Combining forms are used as a connector to join a root word and a suffix or another root word. For example, in the term "gastritis," 'gastr-' is the combining form, representing the stomach. Combining forms facilitate the construction of complex medical terms.
Correct Answer is ["A"]
Explanation
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
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