A nurse is planning care for a client who has a newly placed percutaneous endoscopic gastrostomy (PEG) tube and is agitated and confused. The provider prescribes bilateral wrist restraints. Which of the following actions should the nurse plan to take?
Place the client in a supine position.
Attach the straps to the side rails of the bed frame.
Secure the straps with a square knot.
Remove the restraints every 2 hr.
The Correct Answer is D
A. Place the client in a supine position: The position should prioritize the client’s safety and comfort, considering their condition and the risk of aspiration or discomfort. A supine position may not be the most appropriate for this client’s agitation or confusion.
B. Attach the straps to the side rails of the bed frame: Attaching the restraints to the side rails could be dangerous, as it may cause injury or further agitation. Restraints should be attached to a non-movable part of the bed to ensure the client’s safety and prevent injury due to entrapment.
C. Secure the straps with a square knot: Restraints should not be secured with a square knot, as this could make them difficult to release quickly in an emergency. Instead, the restraint should be fastened in a way that allows for quick removal when needed to ensure the client's safety.
D. Remove the restraints every 2 hr: It is essential to remove restraints at least every 2 hours to check for any signs of injury, provide comfort, and ensure circulation. Removing restraints allows for proper skin care and reduces the risk of complications like pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Call the provider to discuss the client's preference with them and their family: While involving the provider and family is important, the first step should be to educate the client about their options for designating a decision-maker.
B. Explain to the client the process of designating another individual to make decisions for them: The nurse should first provide information about how the client can designate a trusted individual to make decisions for them, such as through a durable power of attorney for healthcare. This allows the client to make an informed decision.
C. Ask the client to discuss these preferences with their family first: The nurse should first empower the client by explaining the process of designating a decision-maker. It is crucial to respect the client’s autonomy in making this decision before involving family.
D. Ask the client if they would like their wishes documented in their health care records: Before documenting, the nurse should ensure the client understands the process of assigning a decision-maker. Documentation is important, but the client needs to understand their options first.
Correct Answer is B
Explanation
A. "You should use woolen blankets on your bed": Woolen blankets are highly flammable and pose a fire risk when oxygen is in use. Clients should avoid using woolen or synthetic materials near oxygen tanks and instead use materials that are less likely to catch fire.
B. "You should purchase a fire extinguisher for your home": Oxygen is highly flammable, and having a fire extinguisher readily available in the home is crucial for safety. The nurse should encourage the client to keep a fire extinguisher nearby in case of any oxygen-related fire emergencies.
C. "You will no longer be able to use an electric razor": Electric razors are safe to use while on oxygen therapy, as they are not typically a fire hazard. However, clients should avoid using razors that require flammable substances, such as shaving cream, around oxygen.
D. "Family members who smoke must do so at least 6 feet away from the oxygen tank": Smoking near oxygen tanks is extremely dangerous, and family members should avoid smoking entirely in areas where oxygen is in use. It is important to maintain a safe distance of at least 10 feet or more from oxygen sources when smoking.
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