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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Raised toilet seats are not a safety risk for older adults. In fact, they can help prevent falls in the bathroom by reducing the distance an individual has to move to sit down and stand up from the toilet.
Choice B rationale
Throw rugs are a safety risk for older adults. They can easily cause tripping and falling, especially if the edges are not secured.
Choice C rationale
A water heater temperature of 54.4°C (130° F) is a safety risk. Water at this temperature can cause burns, especially in older adults who may have decreased sensitivity to heat.
Choice D rationale
Bathtubs with rails are not a safety risk for older adults. Rails can provide support and stability when getting in and out of the bathtub, reducing the risk of falls.
Choice E rationale
Electric cords behind furniture are a safety risk. They can be a tripping hazard and can also pose a fire risk if they are damaged.
Correct Answer is D
Explanation
Choice A rationale
Tachycardia is not a common adverse effect of oxygen therapy. It is more likely to be associated with conditions such as fever, anemia, or hypoxia.
Choice B rationale
Poor skin turgor is a sign of dehydration, not a typical adverse effect of oxygen therapy. Oxygen therapy does not directly affect the body’s hydration status.
Choice C rationale
Excessive pulmonary secretions are not a direct adverse effect of oxygen therapy. Conditions such as pneumonia or bronchitis often cause increased secretions.
Choice D rationale
Cracks in the oral mucous membranes can occur as a result of oxygen therapy. Oxygen can dry out the mucous membranes, leading to discomfort and potential cracking.
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