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 A
Explanation
A. Encourage the client to be assertive is correct. Encouraging assertiveness is important for a client with dependent personality disorder (DPD., as they often have difficulty making decisions or taking initiative. Teaching the client to express their needs, opinions, and desires is a key part of treatment and helps promote independence.
B. Maintain a verbal no-harm contract with the client is incorrect. While maintaining a no-harm contract may be appropriate for clients at risk for self-harm, this is not specific to dependent personality disorder. The main goal is to promote independence and healthy decision-making, not just ensuring safety.
C. Limit the client's social interactions is incorrect. In fact, encouraging healthy social interactions and gradual independence from others is often an important part of treatment for DPD. Limiting interactions could reinforce dependency and hinder progress.
D. Assume responsibility for making the client's decisions is incorrect. The nurse should encourage the client to make their own decisions and foster independence, rather than taking over their decisions, which could worsen the dependent behaviors.
Correct Answer is ["1.5"]
Explanation
Step 1: Determine the desired dose
The desired dose is 60 mg of ibuprofen.
Step 2: Calculate the dose per mL
The available concentration is 50 mg per 1.25 mL.
Step 3: Set up a proportion to find the volume needed
(50 mg / 1.25 mL) = (60 mg / x mL)
Step 4: Solve for x
x = (60 mg 1.25 mL) / 50 mg
x = 1.5 mL
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