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","B","C","D"]
Explanation
A. The client has hypertension and high sodium levels, indicating fluid retention, so a diuretic may be prescribed to help manage these conditions.
B. The client reports difficulty sleeping without drinking several beers a night, indicating a potential alcohol problem. Limiting alcohol intake is a common recommendation for clients with this issue.
C. The client has elevated LDL cholesterol, indicating high-fat intake, so limiting fat intake can help manage this.
D. The client has elevated sodium levels, so reducing sodium intake can help manage this.
E. There is no indication for an antibiotic prescription based on the client's symptoms and lab results.
F. There is no indication of high potassium levels, so limiting foods high in potassium is not necessary.
Correct Answer is ["D","E"]
Explanation
Rationale:
A. These neurological findings are within normal limits and do not require immediate follow-up.
B. These musculoskeletal findings are not indicative of an emergency and can be addressed during routine care.
C. Clear lung sounds are a normal finding and do not require immediate follow-up.
D. An irregular heart rate may indicate an arrhythmia or other cardiovascular issue that requires further assessment and intervention.
E. Hyperactive bowel sounds can indicate a variety of gastrointestinal issues, including bowel obstruction or ileus, which may require immediate intervention or further investigation.
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