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. Ankle is incorrect. The ankle is a hinge joint, which allows for movement in one plane (up and down), not the multidirectional movement characteristic of a ball and socket joint.
B. Shoulder is correct. The shoulder joint is a ball and socket joint. This type of joint allows for movement in multiple directions, including flexion, extension, abduction, adduction, rotation, and circumduction.
C. Knee is incorrect. The knee is a hinge joint, allowing for flexion and extension but not the wide range of motion that a ball and socket joint offers.
D. Metacarpophalangeal is incorrect. The metacarpophalangeal joints (knuckles) are condyloid joints, which allow for movement in two planes but not the full rotational movement of a ball and socket joint.
Correct Answer is B
Explanation
A. "Communicate with personnel about the need for prophylaxis" is incorrect. While it is important to consider prophylaxis for those who may have been exposed to tuberculosis, the first priority is to minimize the risk of transmission from the client to others.
B. "Place a mask on the client" is correct. Placing a mask on the client is the first step in preventing the spread of tuberculosis. This helps contain respiratory droplets that could transmit the bacteria to others.
C. "Contact those who live with the client" is incorrect. While it is important to contact close contacts to assess their risk, this action comes after implementing infection control measures, such as placing a mask on the client.
D. "Notify the local health department" is incorrect. While the health department must be notified about a tuberculosis diagnosis, the immediate priority is to protect others from exposure by masking the client and using appropriate isolation precautions.
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