A nurse has exhausted every effort to keep a confused, postoperative client safe and in bed.
Following The Joint Commission guidelines for use of restraints, which nursing action reflects safe practice?
Applying a cloth restraint to the left hand of the client with an IV catheter in the right wrist.
Positioning the client in the supine position prior to applying wrist restraints.
Ensuring that two fingers can be inserted between the restraint and client's wrist.
Tying an elbow restraint to the raised side rail of the client's bed.
The Correct Answer is C
Choice A rationale
Applying a restraint to an extremity with an intravenous catheter is contraindicated because it can impede the flow of fluids or cause the catheter to become dislodged. Restraints can also increase pressure on the vein, leading to infiltration or phlebitis. Safe practice requires that the restraint be placed on an area that does not interfere with medical devices or circulation. The nurse should always monitor the site of the IV to ensure that the patient's safety measures do not compromise therapy.
Choice B rationale
Positioning a restrained client in a supine position is dangerous because it significantly increases the risk of aspiration if the client vomits. Furthermore, being flat on the back while restrained can lead to respiratory compromise if the client struggles. Standards for restraint use typically recommend a side-lying position or elevating the head of the bed to at least 30 degrees. This ensures that the airway remains clear and that the client's physiological needs are met while their movement is restricted.
Choice C rationale
Ensuring that two fingers can fit between the restraint and the client's skin is a fundamental safety standard to prevent neurovascular injury. If a restraint is too tight, it can compress peripheral nerves and arteries, leading to ischemia, edema, or permanent nerve damage. Checking for adequate space allows for proper blood flow and skin integrity while still achieving the goal of limiting movement. This practice must be accompanied by frequent neurovascular checks, including assessing pulses, color, and temperature.
Choice D rationale
Tying a restraint to a side rail is a serious safety violation. If the side rail is lowered, the restraint could suddenly tighten, causing severe injury or strangulation to the client's limb or body. Restraints must always be secured to the stationary part of the bed frame that moves with the client when the head of the bed is adjusted. This ensures that the tension on the restraint remains constant and prevents accidental injury during routine care or bed adjustments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Step 1 is 1000 mL ÷ 125 mL/hr = 8 hr.
Step 2 is 0900 + 8 hr = 1700. Final calculated answer is 1700.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D","dropdown-group-3":"A","dropdown-group-4":"B"}
Explanation
Choice A rationale
The convalescent period is the final stage of an infectious process where the body repairs tissue damage and returns to its pre-disease state. During this time, the pathogen load has significantly decreased or is entirely eliminated, leading to the disappearance of clinical manifestations. The duration of this phase depends on the severity of the infection and the general health of the host. It is characterized by the restoration of normal physiological functions.
Choice B rationale
The incubation period represents the time between the initial entry of a pathogen into a host and the first appearance of clinical symptoms. During this phase, the pathogen is replicating within the body but has not yet reached a threshold high enough to cause overt illness or localized tissue damage. The length varies greatly depending on the specific infectious agent, the dose of the pathogen, and the effectiveness of the host immune response.
Choice C rationale
The prodromal stage is a critical period where the host begins to manifest early, non-specific symptoms such as malaise, low-grade fever, or fatigue. It is often the time when an individual is most infectious because the pathogen is rapidly multiplying and shedding, yet the individual may not realize they are truly ill. These vague symptoms reflect the initial activation of the innate immune system and the body starting its inflammatory response against the invader.
Choice D rationale
The full stage of illness occurs when the pathogen reaches its peak level of activity, leading to specific signs and symptoms characteristic of the disease. This stage can involve localized manifestations, such as redness and swelling, or systemic issues like high fever and leukocytosis. Laboratory values, such as a white blood cell count exceeding the normal range of 5000 to 10000 cells/mm, often reflect the intensity of the body's defensive battle.
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