A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?
Contact the provider within 48 hr to obtain a prescription for the restraints.
Remove the restraints from the client's wrists every 2 hr.
Check that one finger will fit between the client's wrists and the restraints.
Fasten the restraints' ties to the bed's side rails.
The Correct Answer is B
A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.
B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.
C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.
D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.
B. Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
C. Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.
D. Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.
Correct Answer is B
Explanation
A. "I can take antacids at the same time as this medication.": This is incorrect. Pantoprazole is a proton pump inhibitor (PPI), and taking antacids at the same time can interfere with the medication's effectiveness. It is generally recommended to space out antacids and PPIs by at least 1 hour.
B. "I have to take this medication on an empty stomach.": This is correct. Pantoprazole should be taken on an empty stomach, typically 30 minutes before breakfast, to optimize absorption and effectiveness.
C. "I should expect to have diarrhea while taking this medication.": Diarrhea is not a common side effect of pantoprazole. While side effects such as headache, nausea, and abdominal pain are more common, diarrhea is not typically expected.
D. "I will need to remain upright for 1 hour after taking the medication.": This is incorrect. While it is generally advised to remain upright for a period after taking medications like bisphosphonates, it is not required for pantoprazole. The main instruction for pantoprazole is to take it on an empty stomach before eating.
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