A nurse is caring for a client who is confused and has been placed in wrist restraints.
Which of the following actions should the nurse take while caring for this client? (Select all that apply.)
Check that the client’s restraints are secured with a half-bow knot.
Request that the provider prescribe the restraints as PRN.
Ensure that the client’s wrists are padded.
Loosen the restraints once every 4 hr.
Document client care every 15 min.
Correct Answer : A,C,E
Choice A rationale
Checking that the client’s restraints are secured with a half-bow knot is a good practice. This type of knot is secure but can be easily untied, which is important for quick removal of the restraints if necessary.
Choice B rationale
Requesting that the provider prescribe the restraints as PRN is not a good practice. Restraints should only be used as a last resort and must be ordered by a healthcare provider. The order must specify the reason for the restraints and the duration of use.
Choice C rationale
Ensuring that the client’s wrists are padded is a good practice. Padding helps to prevent skin breakdown and nerve damage.
Choice D rationale
Loosening the restraints once every 4 hours is not a good practice. Restraints should be removed or loosened every 2 hours to allow for skin care and assessment, range of motion exercises, and to check for signs of injury.
Choice E rationale
Documenting client care every 15 minutes is a good practice. This includes documenting the client’s behavior, the type and location of restraints, the frequency of care (at least every 2 hours), and the client’s response to the restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Tachycardia is not a common adverse effect of oxygen therapy. It is more likely to be associated with conditions such as fever, anemia, or hypoxia.
Choice B rationale
Poor skin turgor is a sign of dehydration, not a typical adverse effect of oxygen therapy. Oxygen therapy does not directly affect the body’s hydration status.
Choice C rationale
Excessive pulmonary secretions are not a direct adverse effect of oxygen therapy. Conditions such as pneumonia or bronchitis often cause increased secretions.
Choice D rationale
Cracks in the oral mucous membranes can occur as a result of oxygen therapy. Oxygen can dry out the mucous membranes, leading to discomfort and potential cracking.
Correct Answer is B
Explanation
Choice A rationale
Withholding the medication until the prescribing provider is available could potentially put the patient at risk, especially if the medication is critical for the patient’s health and well-being.
Choice B rationale
Requesting to speak with the provider who is covering for the prescriber is the most appropriate action in this situation. This allows the nurse to clarify the prescription and ensure the safety of the patient.
Choice C rationale
Contacting the pharmacy to confirm that the dosage is safe to administer could be a part of the process, but it should not be the first step. The nurse should first contact a healthcare provider to discuss the prescription.
Choice D rationale
Informing the charge nurse and administering the usual dose of the medication without first consulting with a healthcare provider could potentially put the patient at risk.
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