A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly?

The restraints are attached to the side rails of the client's bed.

The nurse can insert three fingers under the secured restraint.

The restraints are secured with a quick-release knot.

The restraint's soft pad faces away from the client's skin.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. The restraints are secured with a quick-release knot.

Choice A rationale:

The restraints should never be attached to the side rails of the bed. This can cause injury if the side rails are moved up or down. Instead, restraints should be attached to a part of the bed frame that does not move.

Choice B rationale:

The nurse should be able to insert only two fingers under the secured restraint. If three fingers can be inserted, the restraint is too loose and may not effectively prevent the patient from harming themselves or others.

Choice C rationale:

Securing the restraints with a quick-release knot is correct because it allows for easy and rapid removal in case of an emergency.

Choice D rationale:

The soft pad of the restraint should face the client’s skin to prevent skin irritation and injury. If the soft pad faces away from the skin, it can cause discomfort and potential harm.

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Correct Answer is C

Explanation

The correct answer is C.

Hypertension. The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of

cardiovascular events such as stroke, heart attack or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.

A. Ensuring that creases in the stockings are on the front of the client's legs B. Applying the stockings before the client gets out of bed C. Asking the client to point their toes before applying the stockings D. Turning the stockings inside out before applying them

Correct Answer is A

Explanation

Choice A rationale:

This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.

Choice B rationale:

Applying the stockings before the client gets out of bed is correct. Antiembolic stockings should be applied before the client gets out of bed to prevent blood from pooling in the legs, which can help reduce the risk of deep vein thrombosis (DVT).

Choice C rationale:

Asking the client to point their toes before applying the stockings is a correct action. This helps in the proper fitting of the stockings and ensures they are applied smoothly without causing discomfort.

Choice D rationale:

Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.

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A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?

Correct Answer is C

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Correct Answer is A

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