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 D
Explanation
Rationale:
A. Tortuous veins are a common finding in clients with deep-vein thrombosis and may not require immediate reporting.
B. Clammy skin may be a sign of poor circulation but is not specific to deep-vein thrombosis and may not require immediate reporting.
C. Bradycardia is not typically associated with deep-vein thrombosis and may not require immediate reporting.
D. Calf swelling is a common sign of deep-vein thrombosis and should be reported to the provider immediately.
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