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.

Answer and Explanation

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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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.

A. Confidentiality B. Nonmaleficence C. Accountability D. Autonomy

Correct Answer is D

Explanation

A. Confidentiality: Confidentiality refers to the duty to respect and protect the client's private information and not disclose it without the client's consent or appropriate legal authorization.

B. Nonmaleficence: Nonmaleficence means "do no harm." It is the ethical principle that requires healthcare professionals to avoid causing harm to their clients and to balance potential benefits with possible risks.

C. Accountability: Accountability is the ethical principle that refers to the responsibility of healthcare professionals to answer for their actions and decisions in providing care to clients.

D. Autonomy: Correct. Autonomy is the ethical principle that respects a person's right to make their own decisions and about their healthcare. Allowing a client to make decisions about their treatment plan is an example of promoting autonomy and respecting their right to
selfdetermination.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

Correct Answer is D

Explanation

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