A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?
Check that the restraint is tied to a fixed frame of the bed.
Pad bony prominences on the wrist.
Remove the restraint every 4 hr to allow movement.
Tie the restraint with a knot that will tighten when pulled.
The Correct Answer is B
A. Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B. Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C. Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D. Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.
Correct Answer is B
Explanation
A: While volunteering at a local food pantry can be a meaningful activity, it is not the priority when considering Maslow's hierarchy of needs. Physiological needs, such as nutrition and exercise, take precedence.
B: Correct. Attending an exercise program addresses the client's physiological needs (specifically the need for physical activity and health) and takes priority over other options in this context.
C: Finding an enjoyable hobby addresses the client's need for self-fulfillment and self-esteem, which comes at a higher level in Maslow's hierarchy. It is not the immediate priority during discharge planning.
D: Supporting environmental conservation aligns with self-actualization, which is a higher-level need in Maslow's hierarchy. It is not the priority during discharge planning.
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