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
A. Cleaning around the stoma with a moisturizing soap is not recommended. Moisturizing soaps can leave a residue that may interfere with the adhesion of the skin barrier. The client should use warm water or a mild, non-moisturizing soap to clean the area.
B. Pressing on the skin barrier for 30 seconds to ensure that it adheres is correct. This technique helps secure the barrier to the skin, creating a good seal and reducing the risk of leaks.
C. Cutting an opening in the skin barrier that is 1/2 inch larger than the stoma is incorrect. The opening should be about 1/8 inch larger than the stoma to ensure a snug fit, which helps protect the surrounding skin from exposure to effluent.
D. Applying a thin layer of talc powder around the stoma before placing the appliance is not appropriate. Powders are typically used to manage irritated skin but should be avoided unless specifically recommended by a healthcare provider. Overuse can interfere with the appliance’s adhesion.
Correct Answer is C
Explanation
A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.
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