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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "My child still wets the bed at least two times per week." While this is a concern, bedwetting can be a normal developmental behavior for children at this age and does not necessarily indicate a problem unless it persists beyond the typical age range.
B. "I have a difficult time getting my child to eat green vegetables." This is a common concern for parents of young children and typically does not warrant immediate attention, although it may require guidance on healthy eating habits.
C. "My child continually asks me the same questions." Repetition of questions is a normal part of cognitive development in young children and does not indicate an issue by itself.
D. "I have noticed that my child is withdrawn since we switched day care providers." This is the priority concern. Withdrawal or behavioral changes, particularly after a significant event like a change in day care, can indicate stress, anxiety, or possible emotional issues, and the nurse should address this promptly to ensure the child's well-being.
Correct Answer is C
Explanation
A. Tinnitus is not typically associated with the ingestion of tyramine-rich foods while on tranylcypromine.
B. Hyperglycemia is not a common adverse effect related to tyramine interaction with tranylcypromine.
C. Hypertension is correct. Ingesting tyramine-rich foods (such as aged cheese, cured meats, and fermented foods) while taking tranylcypromine, a monoamine oxidase inhibitor (MAOI), can cause a hypertensive crisis. Tyramine is normally broken down by monoamine oxidase (MAO), and inhibiting this enzyme with tranylcypromine can lead to a dangerous increase in blood pressure.
D. Hematuria is not a known adverse effect of tranylcypromine or the ingestion of tyramine-rich foods.
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