A nurse is caring for a client who is pulling at their abdominal wound drains. The provider prescribes wrist restraints for the client's safety. To which of the following parts of the bed should the nurse secure the restraints?

Head of the bed

Moveable portion of the bed frame

Foot of the bed

Side rails closest to the restraints

Answer and Explanation

The Correct Answer is B

A. Head of the bed: Securing restraints to the head of the bed is unsafe because this part does not move with the client’s position changes. It can create tension, leading to injury or impaired circulation.

B. Moveable portion of the bed frame: The safest method is to secure restraints to a moveable part of the bed frame. This ensures the restraints move with the client when the bed position changes, preventing tightening or loosening that could cause harm.

C. Foot of the bed: Tying restraints to the foot of the bed can cause excessive length of restraint straps and increase the risk of entanglement or injury. It also does not provide stable, controlled positioning during movement.

D. Side rails closest to the restraints: Side rails are not stable anchoring points because they move up and down. Attaching restraints here increases the risk of injury if the side rail is lowered, as it could loosen or tighten the restraint unexpectedly.

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Correct Answer is B

Explanation

A. "You shouldn't be concerned because the pump is very easy to use.": This dismisses the client’s concerns and minimizes their feelings. It does not provide an opportunity for the client to express specific worries or receive education.

B. "We can talk more about your worries regarding your pump if you'd like.": This response acknowledges the client’s concerns and invites further discussion. It promotes trust, encourages open communication, and allows the nurse to provide clarification or teaching.

C. "We use these pumps all the time after surgery, and they work great.": While intended to reassure, this response generalizes and fails to address the client’s individual concerns. It may leave the client feeling unheard or invalidated.

D. "Your provider wouldn't prescribe this pump if it wasn't the best option for you.": This shifts responsibility to the provider and avoids addressing the client’s immediate concerns. It does not promote patient-centered communication or therapeutic interaction.

A. Close the client's eyes with paper tape. B. Identify the client using two identifiers. C. Remove the client's pillow to prevent discoloration of the face. D. Remove the client's dentures.

Correct Answer is B

Explanation

A. Close the client's eyes with paper tape: The eyes should be gently closed manually or by placing a small rolled gauze over the eyelids; paper tape can irritate the skin or damage fragile tissue and is not recommended.

B. Identify the client using two identifiers: Proper identification using two identifiers, such as name and medical record number, is essential in postmortem care to ensure accurate handling of the body, compliance with legal requirements, and prevention of errors.

C. Remove the client's pillow to prevent discoloration of the face: The pillow may be adjusted for comfort and positioning, but removing it to prevent discoloration is not standard practice. Discoloration due to livor mortis is a natural process and cannot be prevented by pillow placement.

D. Remove the client's dentures: Dentures should remain in place during postmortem care to maintain facial structure and natural appearance for viewing by family. Removal is only necessary if required for identification or specific postmortem procedures.

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A nurse is caring for a client who is pulling at their abdominal wound drains. The provider prescribes wrist restraints for the client's safety. To which of the following parts of the bed should the nurse secure the restraints?

Nursing Test Bank

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