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 A

Explanation

Performing a simple dressing change is a task that can be safely delegated to an assistive personnel who has received appropriate training and competency validation. It involves removing the old dressing, cleaning the wound if necessary, and applying a new dressing

A. Inject air into the intermediate-acting insulin vial. B. Draw the intermediate-acting insulin into the syringe. C. Inject air into the short-acting insulin vial D. Draw the short-acting insulin into the syringe.

Correct Answer is A,C,D,B

Explanation

The correct order of actions for mixing short-acting and intermediate-acting insulin in the same syringe is as follows:

Inject air into the intermediate-acting insulin vial.
Inject air into the short-acting insulin vial.
Draw the short-acting insulin into the syringe.
Draw the intermediate-acting insulin into the syringe.

The reason for this order is to prevent contamination of the vials. By injecting air into each vial first, you create equalized pressure, making it easier to withdraw the insulin. Drawing the short-acting insulin before the intermediate-acting insulin helps prevent contamination of the short-acting insulin vial with the intermediate-acting insulin.

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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

A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

Correct Answer is A

Explanation

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Correct Answer is A,C,D,B

Explanation

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