A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot.
What action should the nurse take?

Check that three fingers will fit beneath the restraints.

Retie the restraint straps with a slipknot.

Retie the restraint straps to the side rails.

Remove the padding under the wrist restraints.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While it is important to ensure that restraints are not too tight, the issue in this scenario is not related to the tightness of the restraints.
Choice B rationale
Restraints should be tied with a slipknot to allow for quick release if necessary. A double knot may be difficult to untie quickly in an emergency.
Choice C rationale
Restraint straps should not be tied to the side rails. If the side rails are lowered, the restraints could become too loose.
Choice D rationale
The padding under the wrist restraints should not be removed. The padding helps to prevent skin damage and increase the comfort of the patient.

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Correct Answer is A

Explanation

The correct answer is choice A: Provide an adaptive feeding device for the client.

Choice A rationale: Providing an adaptive feeding device, such as a built-up utensil or a swivel spoon, can help clients with limited hand movement feed themselves independently. These devices are designed to make grasping and manipulating utensils easier, promoting independence and self-care.

Choice B rationale: Placing the client in a lateral position might not directly address the issue of limited hand movement, and it could even make feeding more challenging. This position is typically used for clients with swallowing difficulties or those at risk of aspiration.

Choice C rationale: Arranging food groups clockwise on the plate may help clients with visual impairments or cognitive issues, but it would not directly assist a client with limited hand movement during feeding.

Choice D rationale: Initiating a liquid diet for the client is not the most appropriate initial action to address limited hand movement. This might be considered as a last resort if the client is unable to feed themselves with any type of adaptive device or assistance. The priority should be promoting independence and providing appropriate tools to support self-feeding.

A. 5 mL B. 6 mL C. 7 mL D. 8 mL

Correct Answer is C

Explanation

Step 1 is to calculate the amount of amoxicillin in milliliters. Step 2: We know that 250 mg of amoxicillin is in 5 mL.
Step 3: We need to find out how many mL contain 350 mg of amoxicillin. Step 4: Set up a proportion: 250 mg/5 mL = 350 mg/x mL.
Step 5: Cross-multiply and solve for x: 250x = 1750. Step 6: Divide both sides by 250: x = 7 mL2.

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A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot. What action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

Correct Answer is A

Explanation

A nurse is preparing to administer amoxicillin 350 mg PO. The available amoxicillin is 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

Correct Answer is C

Explanation

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A nurse is caring for a client who is confused and has been placed in wrist restraints. Which of the following actions should the nurse take while caring for this client? (Select all that apply.)

A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot.
What action should the nurse take?