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 ["2 ."]

Explanation

Step 1: Identify the prescribed dose and the available dose. The prescribed dose is 500 mg and the available dose is 250 mg per tablet.

Step 2: Use the formula for calculating the number of tablets: (Prescribed dose ÷ Available dose) = Number of tablets.
Step 3: Substitute the values into the formula: (500 mg ÷ 250 mg/tablet) = 2 tablets. So, the nurse should administer 2 tablets.

A. Massage the site after injection to promote absorption. B. Use cold insulin for injection to minimize site pain. C. Rotate the injection site to keep insulin levels consistent. D. Insulin is absorbed most rapidly when injected in the thigh.

Correct Answer is C

Explanation

Choice A rationale
Massaging the site after injection is not recommended. It can cause the insulin to be absorbed more quickly than intended, which could lead to hypoglycemia.
Choice B rationale
Using cold insulin for injection to minimize site pain is not accurate. Insulin should be at room temperature when injected. Cold insulin can make the injection more painful.
Choice C rationale
Rotating the injection site is important to prevent lipodystrophy, a condition that causes abnormal fat deposits at the injection site. It also helps to keep insulin levels consistent.
Choice D rationale
Insulin is not absorbed most rapidly when injected in the thigh. The abdomen is actually the site where insulin is absorbed most quickly.

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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?

Nursing Test Bank

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Correct Answer is ["2 ."]

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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?