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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Free Nursing Study Resources

Correct Answer is ["440"]

Explanation

To calculate the client's net fluid intake, we need to subtract the output (emesis and urine) from

the intake (IV infusion and IV bolus). Intake:

0.9% sodium chloride IV infusion: 600 mL
Cefazolin in dextrose 5% in water IV bolus: 100 mL Output:
Emesis: 200 mL
Voided urine: 40 mL
Urine from straight catheterization: 20 mL Net fluid intake = Intake - Output

Net fluid intake = (600 mL + 100 mL) - (200 mL + 40 mL + 20 mL) Net fluid intake = 700 mL - 260 mL

Net fluid intake = 440 mL

Therefore, the nurse should record the client's net fluid intake as 440 mL.

A. Protective B. Droplet C. Contact D. Airborne

Correct Answer is D

Explanation

Tuberculosis (TB) is primarily transmitted through the airborne route, specifically through the inhalation of respiratory droplets containing Mycobacterium tuberculosis (the bacterium that causes TB).

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is ["440"]

Explanation

A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when with the client?

Correct Answer is D

Explanation

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