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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wearing shoes with smooth soles can increase the risk of slipping; shoes should have good traction for safety.
B. When using a cane, the proper sequence is to move the cane and the weaker leg forward together, then follow with the stronger leg. This provides support as the weaker leg advances.
C. While moving the cane forward is necessary, the distance should typically be short and adjusted based on the client's comfort and stability.
D. The cane should be held on the stronger (unaffected) side to provide support and stability while moving the weaker leg. This technique promotes proper weight distribution and balance during ambulation.
Correct Answer is ["A","B","C","E","F"]
Explanation
Deep Tendon Reflexes 4+: This indicates hyperreflexia, which can be associated with electrolyte imbalances, particularly magnesium deficiency, or central nervous system issues. In this context, the client has a low magnesium level (0.7 mEq/L), which can cause neuromuscular irritability and potentially dangerous complications.
Generalized Weakness and Mild Leg Cramping: While muscle strength is reported as equal, the generalized weakness and cramping suggest possible electrolyte imbalances or neurological issues. The combination with low magnesium levels raises concern for further complications.
Heart Rate Irregular: An irregular heart rate can indicate potential cardiac issues, especially in the context of electrolyte imbalances such as hypomagnesemia and the use of hydrochlorothiazide, which can contribute to electrolyte disturbances.
Bowel Sounds Hyperactive x 4 Quadrants: Although hyperactive bowel sounds can be associated with various conditions, in this case, they may be linked to the client's history of vomiting and possible electrolyte imbalance, warranting follow-up to ensure appropriate management of gastrointestinal symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.