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. Clasping hands behind the body can risk contamination; maintaining a sterile field is crucial.

B. Interlocking fingers and holding hands away from the body above the waist prevents contamination of the gloves and maintains a sterile technique.

C. Keeping hands at the sides may not adequately protect the sterile field; hands should be positioned to minimize contamination risk.

D. Placing hands over the gown may not be appropriate as it does not ensure that the gloves remain sterile and free from contamination.

A. Tighten the abdominal muscles. B. Bend at the waist. C. Keep legs straight. D. Hold object away from the body.

Correct Answer is A

Explanation

A. Tightening the abdominal muscles helps to stabilize the core and reduce strain on the back while lifting, thereby decreasing the risk of injury. This action supports proper body mechanics.

B. Bending at the waist places undue strain on the back muscles and increases the likelihood of injury. Proper lifting technique involves bending at the knees.

C. Keeping the legs straight leads to improper body mechanics, which can strain the back and lead to injury. Bending at the knees is recommended.

D. Holding the object away from the body increases stress on the back muscles. Holding it close to the body helps to distribute the weight evenly.

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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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Correct Answer is A

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