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A nurse is providing teaching to assistive personnel 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 hr.

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

Answer and Explanation

The Correct Answer is C

Restraints should be removed every two hours to assess skin integrity under the restraints and distal circulation

A. A square knot may be difficult to release in the case of an emergency

B. Restraints should be attached to movable parts of the bed to avoid injury during pulling.

D. Allow two fingerbreadths between the restraint and the wrist

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Correct Answer is D

Explanation

A red tag is assigned to clients with a serious life-threatening condition that requires immediate intervention. According to the ABCs of basic life support, the client with a compromised has a life-threatening condition as it might lead to death if left unaddressed.

A, B, C have concerns that requires attention but airway should be addressed first. The other clients have less urgent conditions that can be assigned lower priority tags.

A. Instructing a client on self-administration of a tap water enema B. Suctioning a client's long-term tracheostomy C. Performing a dressing change on a client's peripherally inserted central catheter D. Using a pain rating scale to monitor a client's pain level

Correct Answer is D

Explanation

Rating the pain scale of a client is a low risk task that can be performed by assistive personnel

A. Self-administration of a tap water enema requires careful training which is the responsibility of a nurse

B. Suctioning a tracheostomy tube is a risky procedure within the scope of a registered nurse

C. Replacing a dressing is a procedure that requires infection control measures therefore a nursing intervention

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A nurse is providing teaching to assistive personnel 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

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