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 C
Explanation
Step 1 is to calculate the amount of amoxicillin in milliliters. Step 2: We know that 250 mg of amoxicillin is in 5 mL.
Step 3: We need to find out how many mL contain 350 mg of amoxicillin. Step 4: Set up a proportion: 250 mg/5 mL = 350 mg/x mL.
Step 5: Cross-multiply and solve for x: 250x = 1750. Step 6: Divide both sides by 250: x = 7 mL2.
Correct Answer is D
Explanation
Choice A rationale
The deltoid muscle is not typically used for injections in newborns. It is not as developed as the vastus lateralis and does not have as much muscle mass.
Choice B rationale
The ventrogluteal muscle is generally not used for injections in newborns. It is not as accessible or as well developed as the vastus lateralis.
Choice C rationale
The dorsogluteal muscle is not recommended for injections in newborns due to the risk of damaging the sciatic nerve.
Choice D rationale
The vastus lateralis muscle is the preferred site for intramuscular injections in newborns. It is the most developed muscle in this age group and is free of major nerves and blood vessels.
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