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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale for A: Providing oral care once every 8 hours is not directly related to relieving dyspnea. Oral care addresses comfort related to dry mouth, but it doesn't improve breathing difficulties.

Rationale for B: Repositioning the client every 4 hours can help alleviate dyspnea by improving lung expansion and preventing pooling of secretions. It also helps in reducing pressure injuries, promoting comfort, and preventing complications.

Rationale for C: Placing the head of the bed flat can exacerbate dyspnea by hindering lung expansion. It is recommended to elevate the head of the bed to improve air exchange and breathing.

Rationale for D: While using a fan can help with the sensation of breathlessness, repositioning every 4 hours is a more direct action to support ventilation and reduce dyspnea.

A. "You can allow your family to visit as often as you wish." B. "Tell me your expectations about activities related to the end-of-life." C. "We can talk to the provider about incorporating nonpharmacological pain management in your care." D. "You can provide the name of a spiritual support person we can contact for you."

Correct Answer is B

Explanation

Rationale:

A. This response addresses the client's desire to have family visits but does not directly address the client's concerns about end-of-life care.

B. Asking the client to express their expectations about activities related to the end-of-life allows the nurse to understand the client's wishes and concerns and to provide appropriate support.

C. This response addresses the client's need for pain management but does not directly address the client's concerns about end-of-life care.

D. This response addresses the client's need for spiritual support but does not directly address the client's concerns about end-of-life care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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