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 is attached to the side rails of the bed.

The restraint the strap is tied into a knot.

The nurse can insert two fingers under the restraint.

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

Answer and Explanation

The Correct Answer is C

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.

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Correct Answer is D

Explanation

A. "You will receive moderate sedation prior to the procedure.": Moderate sedation is not typically required for a thoracentesis. Instead, local anesthesia is used at the puncture site to minimize discomfort. The client remains awake, able to follow instructions, and does not require the same level of monitoring associated with moderate sedation.

B. "You will need to lie on your affected side for 30 minutes following the procedure.": After a thoracentesis, clients are usually positioned on the unaffected side to allow the lung on the affected side to re-expand and to minimize the risk of complications such as pneumothorax. Lying on the affected side could worsen the client's condition post-procedure.

C. "You will not be able to eat or drink four hours prior to the procedure.": Thoracentesis is not a gastrointestinal or airway procedure that necessitates fasting beforehand. Clients are typically allowed to eat and drink normally unless another procedure requiring fasting is planned, as the risk of aspiration is minimal with thoracentesis.

D. "You will be placed leaning over a bedside table during the procedure.": Clients undergoing thoracentesis are positioned sitting upright, leaning slightly forward over a bedside table with pillows for support. This position helps spread the ribs apart and provides the best access to the pleural space while minimizing the risk of lung injury.

A. Limit periods of sitting in a chair to 4 hr. B. Avoid the use of draw sheets for repositioning C. Use a no-rinse perineal cleanser after incontinence. D. Keep the head of the client's bed elevated to 45.

Correct Answer is C

Explanation

A. Limit periods of sitting in a chair to 4 hr: Clients with urinary incontinence should avoid prolonged sitting because it increases pressure on the skin and raises the risk of skin breakdown. Sitting should be limited to shorter periods with frequent repositioning to protect skin integrity.

B. Avoid the use of draw sheets for repositioning: Draw sheets are helpful for repositioning clients safely and reducing friction and shear forces on the skin. Avoiding their use would increase the risk of skin injury, especially in clients with incontinence who are already vulnerable.

C. Use a no-rinse perineal cleanser after incontinence: Using a no-rinse perineal cleanser helps maintain skin hygiene, removes urine and feces gently, and prevents irritation or breakdown. It is an important part of incontinence care to protect the client's skin health.

D. Keep the head of the client's bed elevated to 45º: Elevating the head of the bed to 45º degrees is helpful for respiratory support but does not directly address urinary incontinence. Bed positioning should be adjusted based on overall client needs, not specifically to manage incontinence.

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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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Correct Answer is C

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