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 B
Explanation
Choice A rationale
Assisting the guest to the floor and beginning mouth-to-mouth resuscitation is not the appropriate initial response. The guest’s symptoms indicate choking, and the Heimlich maneuver is the recommended first aid response.
Choice B rationale
The Heimlich maneuver is the correct response when someone is choking. The guest’s symptoms of a weak cough, inability to speak, and grasping the throat are classic signs of choking.
Choice C rationale
Observing the guest before taking further action is not appropriate in this situation. Immediate action is required to clear the guest’s airway.
Choice D rationale
Slapping the guest on the back is not the recommended response for choking in adults. It can potentially cause the object to become more deeply lodged in the throat.
Correct Answer is D
Explanation
Choice A rationale
Pursed-lip breathing can help improve oxygenation and reduce shortness of breath in clients with COPD. However, it is not the priority action when a client reports difficulty breathing.
Choice B rationale
Increasing the oxygen flow rate without a physician’s order can lead to oxygen toxicity or suppress the respiratory drive in clients with COPD. Therefore, this is not the priority action.
Choice C rationale
Coughing and expectorating secretions can help clear the airways, but it is not the priority action when a client reports difficulty breathing.
Choice D rationale
Evaluating the client’s respiratory status is the priority action. The nurse should assess the client’s breath sounds, respiratory rate, use of accessory muscles, and oxygen saturation to determine the severity of the client’s difficulty breathing and guide further interventions.
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