A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?

Remove one restraint at a time.

Tie the restraints to the side rail,

Secure restraints with a square knot

Remove the restraints every 3 hr

Answer and Explanation

The Correct Answer is A

When using restraints for the safety of the client and others, it is important to follow proper procedures to ensure the client's well-being and minimize the risk of injury. Removing one restraint at a time allows for better control and assessment of the client's behavior and response. It also helps maintain the client's safety by ensuring that at least one limb is restrained during the process.

Restraints should never be tied to the side rail as it can cause serious harm or injury to the client. Restraints should be attached to an immobilization device specifically designed for that purpose, such as a bed frame or a designated restraint chair.

Restraints should be secured with a quick-release mechanism, such as a buckle or Velcro, that allows for quick and easy removal in case of emergency or the need for rapid intervention. Tying restraints with a square knot can delay the removal process and may compromise the client's safety.

Restraints should only be used when necessary and as prescribed by the healthcare provider. The frequency and duration of restraint use should be based on the client's condition and the specific order from the healthcare provider. It is not appropriate to remove restraints based solely on a time schedule without considering the client's individual needs and safety. Regular assessments should be conducted to determine if continued use of restraints is required or if alternative interventions can be implemented.

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Correct Answer is C

Explanation

A potassium level of 5.8 mEq/L is above the normal range (typically 3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can have serious implications for the client's cardiac function and requires medical intervention. The nurse should notify the healthcare provider promptly so that appropriate actions can be taken to address the high potassium level.

A. Ensure the client is free of metal objects B. Monitor the client for pain in the suprapubic region C. Assist the client with a bowel cleansing. D. Administer 240 mL (8 oz) of oral contrast before the procedure

Correct Answer is A

Explanation

An IVP is a radiographic procedure that involves injecting a contrast dye into the vein to visualize the urinary tract. Metal objects can interfere with the imaging process and may need to be removed or avoided during the procedure. The nurse should assess the client for any metal objects, such as jewelry or clothing accessories, and ensure they are removed before the procedure to ensure accurate imaging.

Monitoring the client for pain in the suprapubic region is not directly related to an IVP. Suprapubic pain may be associated with other urinary tract procedures or conditions, but it is not a specific concern during an IVP.

Assisting the client with a bowel cleansing is not necessary for an IVP. Bowel cleansing is typically done for procedures involving the lower gastrointestinal tract, such as colonoscopy or barium enema.

Administering oral contrast before the procedure is also not necessary for an IVP. In an IVP, the contrast dye is administered intravenously, not orally. Oral contrast is typically used for imaging studies of the gastrointestinal tract, such as an upper GI series or CT scan of the abdomen.

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A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?

Nursing Test Bank

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