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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "Take this medication daily to prevent headaches": Sumatriptan is not used as a preventive medication; it is prescribed for the acute treatment of migraine attacks. Daily use would increase the risk of side effects without providing prophylactic benefit.

B. "You can bathe with the patch in place.": The transdermal sumatriptan patch is designed to stay adhered during activities such as bathing or showering. This makes it convenient for clients to use without interrupting their treatment during daily hygiene routines.

C. "Activate the patch 30 minutes after application.": The patch is self-activated at the time of application. Waiting 30 minutes before activation would delay symptom relief and is not part of the prescribed use.

D. "Use contraception while taking this medication.": While some medications require contraception due to teratogenic risks, sumatriptan is not contraindicated in this way. Clients should still discuss pregnancy planning with their provider, but contraception is not a required instruction.

A. Shake the NPH insulin until it is well mixed. B. Draw up the NPH insulin into the syringe first. C. Inject air into the regular insulin first. D. Discard regular insulin that appears cloudy.

Correct Answer is C

Explanation

A. Shake the NPH insulin until it is well mixed: NPH insulin should be gently rolled between the palms, not shaken vigorously, to avoid creating bubbles and affecting its potency. Gentle mixing ensures proper suspension without compromising the insulin.

B. Draw up the NPH insulin into the syringe first: The correct technique is to draw up regular (clear) insulin first, followed by NPH (cloudy) insulin, to prevent contaminating the regular insulin with the longer-acting NPH. Drawing NPH first can alter the regular insulin’s action.

C. Inject air into the regular insulin first: Injecting air into both insulin vials before drawing up doses equalizes pressure and facilitates accurate measurement. Air is injected first into the regular insulin vial to maintain proper technique when mixing insulins.

D. Discard regular insulin that appears cloudy: Regular insulin is a clear solution. Cloudiness indicates contamination or expiration, so cloudy regular insulin should never be used. This instruction reinforces proper medication safety practices.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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