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 B

Explanation

A. Orthostatic hypotension is not a direct risk factor for cardiovascular disease, though it can be related to other health issues.

B. Type 1 diabetes mellitus increases the risk for cardiovascular disease due to chronic hyperglycemia, which can damage blood vessels over time.

C. Osteoporosis is a risk for bone health but is not a cardiovascular risk factor.

D. A BMI of 24 is within the normal range and does not pose a cardiovascular risk.

A. Calf swelling B. Bradycardia C. Clammy skin D. Tortuous veins

Correct Answer is A

Explanation

A. Calf swelling is a common sign of deep-vein thrombosis (DVT) and should be reported as it could indicate a blood clot, which may lead to serious complications if not addressed.

B. Bradycardia is unrelated to DVT and may be due to other underlying conditions.

C. Clammy skin could indicate shock or other systemic issues but is not directly associated with DVT.

D. Tortuous veins are generally a sign of chronic venous insufficiency, not an acute finding indicative of DVT.

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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

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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