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.
Check the client's range of motion every 6 hr.
Secure the restraints with a square knot.
Make sure two fingers fit under the restraints.
The Correct Answer is D
Rationale:
A. Wrist restraint orders typically require renewal every 24 hours, not every 36 hours.
B. Checking the client's range of motion every 6 hours is not specific to the use of wrist restraints.
C. Secure the restraints with a quick-release knot, not a square knot, to allow for quick removal in case of emergency.
D. Making sure two fingers fit under the restraints is important to ensure that they are not too tight and do not cause injury to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. This response addresses the client's desire to have family visits but does not directly address the client's concerns about end-of-life care.
B. Asking the client to express their expectations about activities related to the end-of-life allows the nurse to understand the client's wishes and concerns and to provide appropriate support.
C. This response addresses the client's need for pain management but does not directly address the client's concerns about end-of-life care.
D. This response addresses the client's need for spiritual support but does not directly address the client's concerns about end-of-life care.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
A. Physical therapy for muscle-strengthening and balance-training is expected because the client has a left lateral malleolus fracture and a Bone Mineral Density DEXA scan of -3.8. Physical therapy can help with rehabilitation and prevent future falls.
B. Calcium supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Calcium supplementation is essential for bone health.
C. Vitamin D supplementation is expected because the client has a Bone Mineral Density DEXA scan of -3.8, indicating osteoporosis. Vitamin D supplementation is essential for calcium absorption and bone health.
D. A home health evaluation of home safety is expected because the client lives alone and has a history of falling. A home health evaluation can help identify potential hazards and improve safety.
E. Increasing caffeine intake is unexpected because the client already reports consuming at least 3 cups of coffee daily. Increasing caffeine intake further may not be advisable due to potential side effects, such as increased heart rate and blood pressure.
F. Increasing daily sun exposure is unexpected because the client has osteoporosis and a history of falling. Excessive sun exposure can increase the risk of skin cancer, and the client may not be able to safely spend extended periods of time in the sun due to mobility limitations. Additionally, vitamin D supplementation is usually recommended over sun exposure for individuals with osteoporosis.
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