A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?

To prevent contractions in the hand.

To prevent skin breakdown.

To prevent decrease perfusion in the lower extremities.

To prevent pooling of blood in the hand.

Answer and Explanation

The Correct Answer is A

A. To prevent contractions in the hand:

The use of hand and wrist rolls helps prevent contractures, which are permanent shortening of muscles or joints. This is particularly important in comatose patients or those with limited mobility to maintain proper hand positioning and prevent deformities.

B. To prevent skin breakdown:

While proper positioning can contribute to preventing skin breakdown, the primary purpose of hand and wrist rolls, in this context, is to address the risk of contractures rather than skin breakdown.

C. To prevent decreased perfusion in the lower extremities:

The action described is specifically related to the hands and wrists, not the lower extremities. It is not designed to prevent decreased perfusion in the lower extremities.

D. To prevent pooling of blood in the hand:

While maintaining proper hand positioning may contribute to optimal circulation, the primary purpose is to prevent contractures rather than addressing blood pooling.

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Correct Answer is A

Explanation

A. Tie it to the bed frame with a quick release knot.This option is correct because securing the restraint to the bed frame ensures that the client cannot easily remove it, while a quick release knot allows for rapid removal in case of an emergency.

B. Strap the restraint with a square knot to the head of the bed.While a square knot may be secure, it is not considered a quick-release method, which is essential for the safety of the client.

C. Use a quick release knot to tie the restraint to the side rail.Tying a restraint to the side rail can pose a risk because if the side rail is lowered, it may create a situation where the restraint is loose or ineffective. It is safer to secure it to the bed frame instead.

D. Assist with range of motion at least every 3 hours.While providing range of motion is important to prevent complications from immobility, it does not address how to secure the restraint itself. Regular assessments and range of motion exercises should be part of the overall care plan but are not directly related to securing the restraint.

A. 20 bpm B. 10 bpm C. 09 bpm D. 18 bpm

Correct Answer is B

Explanation

A. 20 bpm: This is twice the calculated rate, so it's significantly higher than observed.

B. 10 bpm: This matches closely with the calculated rate of approximately 10.23 breaths per minute.

The scenario describes the nurse counting the client's breaths starting from when the second hand of the clock was at 12 and ending just past 5, and the client completed 9 breaths during this time frame.

Counting Period:

From just past 12 to just past 5 on the clock, the time span is approximately 53 seconds.

Number of Breaths:

The client completed 9 breaths within this time frame.

Now, to calculate the respiratory rate:

Respiratory rate = (Number of breaths / Time in minutes)

Respiratory rate = (9 breaths / 0.88 minutes) (53 seconds converted to minutes)

After calculation, the respiratory rate is approximately 10.23 breaths per minute.

C. 09 bpm: This is a lower value than observed and doesn't align with the counted breaths.

D. 18 bpm: This is close to double the observed rate, which doesn't match with the counted breaths within the time frame.

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A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?

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Correct Answer is A

Explanation

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Explanation

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