A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Assess skin temperature and color before applying the restraints.
Ensure that the client's bed is in the lowest position.
Secure restraints to allow three fingers to slide under the restraints.
Pad bony prominences before applying the restraints.
Attach the client's restraints to the bed rail.
Correct Answer : A,B,C,D
When planning care for a client who has a prescription for extremity restraints on both wrists, the nurse should assess the client's skin temperature and color before applying the restraints to ensure that there is no circulation impairment. The nurse should also ensure that the client's bed is in the lowest position to prevent falls. The restraints should be secured to allow three fingers to slide under them to prevent injury and ensure proper circulation. Bony prominences should be padded before applying the restraints to prevent pressure injuries.
Option e is incorrect because attaching the client's restraints to the bed rail can cause injury if the bed rail is moved or adjusted.
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Correct Answer is B
Explanation
The correct answer is that the nurse should recommend the client to eat a light carbohydrate snack before bedtime. Eating a light carbohydrate snack before bedtime can help promote sleep by increasing the level of tryptophan in the brain, which can help induce sleep.
Options a, c and d are not appropriate interventions for insomnia. Taking a 30-min nap daily can disrupt nighttime sleep and worsen insomnia. Exercising 1 hr before bedtime can increase alertness and make it harder to fall asleep. Drinking a cup of hot cocoa before bedtime can also disrupt sleep due to its caffeine content.
Correct Answer is B
Explanation
The correct answer is that the nurse should turn off the faucet with a clean, dry paper towel when performing hand hygiene at the beginning of his shift. This helps to prevent recontamination of the hands by touching the faucet with clean hands.
Options a, c and d are not correct actions for performing hand hygiene. Rubbing hands together to cause friction for at least 10 seconds, drying hands by working from the forearms down to the fingertips and keeping hands above elbow level when washing are not recommended practices for hand hygiene.
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