A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
Make sure four fingers fit between the restraint and the client's body.
Apply the belt restraint over the client's gown.
Check the client's skin integrity every 4 hr.
Tie the belt restraint to the side rail of the bed.
The Correct Answer is B
Rationale:
A. Ensuring that four fingers fit between the restraint and the client's body is important to prevent injury and discomfort.
B. Applying the belt restraint over the client's gown may lead to slippage and ineffective restraint.
C. Checking the client's skin integrity every 4 hours is important, but it is not specific to the use of a belt restraint.
D. Tying the belt restraint to the side rail of the bed is not appropriate because it can restrict movement and cause injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Regular clinical breast examinations by a healthcare provider are recommended for all women, typically starting at age 30, regardless of family history, as part of early detection efforts for breast cancer.
B. While mammograms are important for breast cancer screening, the age at which they should start may vary based on individual risk factors and guidelines from different organizations.
C. Breast ultrasound may be used in specific cases but is not typically recommended as a routine screening tool for breast cancer in asymptomatic women without specific risk factors.
D. Breast self-examinations are important for women to become familiar with their breasts and detect any changes, but the age at which they should start may vary based on individual risk factors and guidelines.
Correct Answer is C
Explanation
Rationale:
A. Administering diuretics in the evening may increase the client's need to urinate and disrupt sleep.
B. Using overhead lighting when checking equipment may disrupt the client's sleep and should be avoided.
C. Keeping the door to the client's room closed can reduce noise and disturbances from the hallway, promoting a more restful sleep environment.
D. Providing snug-fitting nightwear may be uncomfortable and restrict movement during sleep.
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