A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?
"I will tie a restraint to the portion of the bed that moves when the head of the bed is moved."
“I will the restraints in double knots."
"I will put four side rails up if a client is confused."
“I will ensure that restraints fit tightly against the client."
The Correct Answer is A
A. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved.": This is the safest method because it prevents excess tightening or loosening of the restraint as the bed is adjusted. Using quick-release knots ensures the restraint can be removed quickly in an emergency.
B. "I will tie the restraints in double knots.": Double knots are unsafe because they are difficult to untie quickly if the client requires emergency release. Quick-release knots are the standard to promote both safety and rapid removal.
C. "I will put four side rails up if a client is confused.": Raising all four side rails is considered a form of restraint and poses risks for injury, such as entrapment or falls when attempting to climb out. It should not be used for confused clients.
D. "I will ensure that restraints fit tightly against the client.": Restraints should never be tight; there should be enough space to insert two fingers between the restraint and the client’s skin. Tight restraints can impair circulation, cause skin breakdown, and increase injury risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Position the wrapped package on the bedside table so the outer flap opens towards her: The outer flap should always open away from the nurse to avoid reaching over the sterile field, which can contaminate it. Opening toward oneself increases the risk of contamination.
B. Place sterile supplies within the 2.54 cm (1 in) border of the sterile field: The 1-inch border around the sterile field is considered contaminated. Placing sterile items within this area makes them unsterile and unsuitable for use in the procedure.
C. Use sterile forceps to move the sterile items on the sterile field: Once an item is placed on the sterile field, it can be moved with sterile gloves or kept in place. Using sterile forceps unnecessarily increases the risk of contamination and is not required for maintaining sterility.
D. Hold gauze packages 7.6 cm (3 in) above the sterile field: Sterile items should be dropped onto the sterile field from a height of 6–12 inches to maintain sterility while avoiding contamination. Holding the gauze package 7.6 cm above meets this standard practice.
Correct Answer is D
Explanation
A. Levofloxacin: This fluoroquinolone antibiotic is primarily associated with side effects such as tendon rupture, QT prolongation, and central nervous system disturbances. Nephrotoxicity is not a common adverse effect of levofloxacin.
B. Ofloxacin: Also a fluoroquinolone, ofloxacin has similar side effects to levofloxacin, including gastrointestinal upset and neurologic symptoms. It is not linked to significant nephrotoxicity compared to aminoglycosides.
C. Ceftriaxone: This cephalosporin antibiotic is generally well tolerated and not strongly associated with nephrotoxicity. It may cause biliary sludging or gastrointestinal issues but rarely causes renal injury.
D. Gentamicin: Gentamicin, an aminoglycoside, is well known for its risk of nephrotoxicity due to accumulation in renal tubules. It can cause acute tubular necrosis, particularly with prolonged use or high doses, making it the most nephrotoxic option listed.
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