A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

Request a prescription renewal from the provider every 36 hr.

Make sure two fingers fit under the restraints.

Check the client's range of motion every 6 hr.

Secure the restraints with a square knot.

Answer and Explanation

The Correct Answer is B

A. Restraint prescriptions typically need to be renewed at least every 24 hours, not every 36 hours, to comply with regulatory standards.

B. Ensuring that two fingers fit under the restraints is essential to confirm that they are not too tight, allowing for circulation and comfort while still securing the client.

C. Checking the client's range of motion should occur more frequently than every 6 hours; ideally, it should be assessed more regularly to prevent complications.

D. Restraints should be secured using a quick-release knot, not a square knot, to ensure they can be removed easily in an emergency.

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Correct Answer is C

Explanation

A. Documentation is important but should occur after addressing the client’s concerns.

B. Returning the medication is appropriate if the client ultimately refuses it, but initial discussion is needed first.

C. Informing the client of the potential consequences of refusing their medication respects their autonomy while ensuring they understand how it may impact their health. This is the first step to address concerns and provide education.

D. Notifying the provider is necessary if the client continues to refuse after education, as the provider may need to adjust the prescription.

A. Hyperkalemia B. Hypocalcemia C. Hyponatremia D. Hypermagnesemia

Correct Answer is C

Explanation

A. Hyperkalemia is an increase in potassium levels, which may occur with certain conditions but is not the most common finding with vomiting and diarrhea.

B. Hypocalcemia may occur due to various factors but is not a typical result of vomiting and diarrhea.

C. Hyponatremia is a decrease in sodium levels and is expected in cases of prolonged vomiting and diarrhea due to the loss of fluids and electrolytes, making it the most likely finding.

D. Hypermagnesemia is not typically associated with vomiting and diarrhea; it is more related to renal failure or excessive intake of magnesium.

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Body system	Findings
Neurological	Alert and oriented to person, place, and time: deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	Lungs clear
Cardiovascular	Heart rate irregular: Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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