A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

Attach the restraints to the fixed portions of the frame of the client's bed.

Remove the client's restraints every 2 hr

Secure the client's restraints with a square knot.

Allow 1 fingerbreadth between the restraint and the client's wrists.

Answer and Explanation

The Correct Answer is D

A.   Restraints should not be attached to the bed frame. Instead, they should be secured to a movable part of the bed (such as side rails) to prevent injury. Attaching restraints to the bed frame can cause harm to the patient and limit their mobility.
B.   While it's essential to assess and reposition restraints regularly, removing them entirely every 2 hours is not recommended unless the patient's condition allows for it. Restraints should be removed and repositioned at least every 2 hours to assess skin integrity, circulation, and comfort. However, they should not be removed entirely unless necessary.
C.   Square knots are not recommended for restraining patients because they can be difficult to untie quickly in case of an emergency. Quick-release buckles or Velcro fasteners are safer options.
D.   Allowing 1 fingerbreadth between the restraint and the client's wrists ensures proper circulation and prevents excessive tightness. Properly fitting restraints prevent injury while maintaining patient safety.

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Correct Answer is A

Explanation

A. The nurse's role in the informed consent process typically includes witnessing the client's signature on the consent form. This action confirms that the client has signed the document voluntarily and understands the consent form's content. The nurse does not provide the consent but ensures that the
client’s signature is properly recorded.
B. Teaching the client about the risks involved with the procedure is not typically within the nurse's role. This task is usually the responsibility of the provider or surgeon who performs the procedure. The provider is responsible for explaining the risks, benefits, and alternatives to the client.
C. Explaining the procedure to be performed is also not typically within the nurse’s role. This explanation should be done by the provider or surgeon who will perform the procedure. The provider has the detailed knowledge necessary to describe the procedure, including its steps, risks, and expected outcomes.
D. Providing information about alternative procedure options is part of the informed consent process but is generally done by the provider. The provider is responsible for presenting all possible alternatives to the client, along with their potential risks and benefits.

A. A client who has fixed pupils B. A client who experienced a brief loss of consciousness C. A client who has a compromised airway D. A client who has major burns covering 70% of their body

Correct Answer is C

Explanation

A. Fixed pupils indicate a potential severe neurological issue, such as brain injury or death. However, this sign alone does not necessarily mean that immediate intervention would be effective. In a triage setting, clients with fixed pupils are often classified as having a very poor prognosis and might be tagged as black (deceased) if their condition is deemed non-salvageable, rather than red.
B. A brief loss of consciousness (syncope) can be a sign of various issues, but it might not immediately signify a life-threatening condition requiring immediate intervention. In a triage setting, this client would likely be assessed for further symptoms and categorized based on their overall condition and immediate needs.
C. A compromised airway is a critical and life-threatening condition. In triage, clients with compromised airways are given a red tag because they require immediate intervention to secure the airway and
ensure breathing. Without prompt treatment, this client’s chances of survival are significantly reduced.
D. While major burns covering 70% of the body are severe and life-threatening, the immediate need for intervention and the likelihood of survival with immediate treatment are crucial considerations. In a triage scenario, such clients are often tagged based on the availability of resources and their overall prognosis.

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A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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