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

Secure the client's restraints with a square knot

Attach the restraints to the fixed portion of the frame of the client's bed

Remove the client's restraints every 2 hours

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

Answer and Explanation

The Correct Answer is B

A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.

B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.

C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.

D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A: Ambulate the client

Ambulating the client is a task that can be safely delegated to assistive personnel. The client has right-sided weakness following a cerebrovascular accident, and assistive personnel can help the client move around safely¹.

Choice B: Document the client's urine output

Documenting the client's urine output is another task that can be delegated to assistive personnel. They are trained to measure and record urine output, which is important for monitoring the client's fluid balance¹.

Choice C: Assist the client with completing their food menu

Assistive personnel can also help the client with completing their food menu. This task does not require clinical judgement and can be safely delegated¹.

Choice D: Instruct the client on swallowing techniques

Instructing the client on swallowing techniques should not be delegated to assistive personnel. This task requires specialized knowledge and skills that are beyond the scope of practice for assistive personnel².

Choice E: Obtain the client's vital signs

Obtaining the client's vital signs is a task that can be delegated to assistive personnel. They are trained to accurately measure and record vital signs, which are crucial for monitoring the client's health status¹.

Choice F: Refer the client to the speech language pathologist

Referring the client to the speech language pathologist is not a task that can be delegated to assistive personnel. This decision requires clinical judgement and should be made by the nurse².

A. A client who is receiving heparin and has an aPTT of 34 seconds. B. A client who has type 1 diabetes and uses an insulin pump. C. A client who has orthostatic hypotension and is receiving IV fluids. D. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL.

Correct Answer is C

Explanation

Choice A reason: An aPTT (activated partial thromboplastin time) of 34 seconds is within the therapeutic range for heparin therapy. There is no immediate need for an interdisciplinary conference based solely on this result. The nurse can continue monitoring the client's aPTT and adjust heparin dosing as needed. The aPTT value is appropriate for the client's condition, and no urgent intervention is required.

Choice B reason: Insulin pump management primarily involves coordination between the patient and the diabetes care team. While education and ongoing support are essential, an interdisciplinary conference is not typically necessary for routine insulin pump use. Insulin pump management is a well-established process that does not require immediate collaboration among multiple disciplines.

Choice C reason: Orthostatic hypotension is a condition where blood pressure drops significantly upon standing. IV fluids are commonly used to manage orthostatic hypotension by increasing blood volume and improving blood pressure regulation. An interdisciplinary conference would involve collaboration among healthcare professionals to address the client's specific needs related to orthostatic hypotension, fluid management, and prevention of complications. Orthostatic hypotension requires coordinated efforts from various disciplines to optimize care.

Choice D reason: While albumin levels are relevant for assessing nutritional status and wound healing, this specific scenario does not necessitate an interdisciplinary conference. Pressure ulcer prevention and management can be addressed through routine nursing assessments and interventions. Pressure ulcer risk and albumin levels can be managed within the nursing scope without immediate interdisciplinary collaboration.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is delegating care for a client who has right-sided weakness following a cerebrovascular accident. The client coughs when eating and voice becomes hoarse after swallowing. Select the four tasks the nurse should assign to an assistive personnel.

Correct Answer is ["A","B","C","E"]

Explanation

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Correct Answer is C

Explanation

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