A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

The restraint tie strap is tied into a knot.

The restraint is attached to the side rails of the bed.

The skin under the restraint is cool and has changed color.

The nurse can insert two fingers under the restraint.

Answer and Explanation

The Correct Answer is D

Rationale:

A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.

B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.

C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.

D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.

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Correct Answer is B

Explanation

Rationale:

A. Arterial blood gases: While ABGs assess respiratory and metabolic balance, they are not routinely monitored for clients on furosemide. This test is more relevant for clients with severe respiratory or acid-base disorders, not as a direct indicator of diuretic therapy effects.

B. Blood urea nitrogen: Furosemide is a loop diuretic that can affect kidney function by reducing circulating blood volume. Monitoring BUN helps assess renal perfusion and detect early signs of dehydration or nephrotoxicity associated with diuretic use.

C. Prothrombin time: PT evaluates coagulation status, typically in clients taking anticoagulants like warfarin. Furosemide does not affect clotting pathways, so PT monitoring is unnecessary in this context unless the client is on anticoagulants for another condition.

D. Thyroid stimulating hormone: TSH measures thyroid function but is not influenced by furosemide. There is no established link between furosemide and thyroid activity that would necessitate routine TSH monitoring for clients taking this medication.

A. Deliver 2 L of oxygen via partial nonrebreather mask. B. Give epinephrine intramuscularly C. Administer diazepam PO. D. Notify the radiology department

Correct Answer is B

Explanation

Rationale:

A. Deliver 2 L of oxygen via partial nonrebreather mask: While oxygen can support airway function, it does not address the underlying cause of anaphylaxis. Airway closure due to an allergic reaction requires immediate pharmacologic intervention, not just oxygen delivery.

B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis. It counteracts bronchoconstriction, airway edema, and hypotension by stimulating alpha and beta receptors, and should be administered immediately when signs of airway compromise are present.

C. Administer diazepam PO: Diazepam is used for anxiety or seizures, not for acute allergic reactions. It has no effect on reversing airway swelling or bronchospasm and would delay the appropriate emergency treatment needed in this situation.

D. Notify the radiology department: Contacting the radiology department is not relevant or urgent in this scenario. The client is experiencing a life-threatening reaction that requires immediate medical intervention, not communication with non-emergency services.

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A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

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