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 C

Explanation

A. Discontinued medications do not provide actionable information for the receiving facility, as they are no longer relevant to the client's ongoing care. Including this information may lead to confusion about the current treatment plan.
B. Resolved health conditions are not a priority to communicate because they do not require further monitoring or intervention. Focus should be placed on active health concerns and ongoing care needs.
C. The frequency of vital sign collection is critical information for the receiving facility to maintain continuity of care and ensure appropriate monitoring of the client's condition. This detail helps guide the long-term care staff in managing the client’s ongoing health needs effectively.
D. Completed nursing interventions are not typically included in the transfer report as they have already been addressed and do not impact future care. The focus should remain on ongoing and future interventions required for the client.

A. Restrict the client's visitors to the immediate family. B. Assign the client to a negative pressure airflow room. C. Discard personal protective equipment outside the client's room. D. Have the client wear a HEPA mask during transportation throughout the facility.

Correct Answer is B

Explanation

A. Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis
may need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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