A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?
The nurse can insert one finger between the client's wrist and the restraint.
The padding of the restraints is against the client's bony prominences.
The AP ties the straps of the restraints in a double knot.
The AP ties the restraints to the side rails
The Correct Answer is B
Answer: B. The padding of the restraints is against the client's bony prominences.
A. The nurse can insert one finger between the client's wrist and the restraint.
The proper guideline is that the nurse should be able to insert two fingers between the client's wrist and the restraint. This ensures the restraint is snug but not too tight, which helps prevent impaired circulation and skin breakdown.
B. The padding of the restraints is against the client's bony prominences.
This is the correct practice. The padding of the restraints should always be applied to protect the client’s skin and prevent injury, particularly over bony prominences where the risk of pressure sores or skin breakdown is higher.
C. The AP ties the straps of the restraints in a double knot.
A double knot should not be used because it can make it difficult to quickly release the restraint in an emergency. A quick-release knot should always be used to ensure the restraint can be removed easily and promptly if needed.
D. The AP ties the restraints to the side rails.
Restraints should never be tied to movable parts like side rails, as raising or lowering the side rails could cause injury. Restraints should be secured to a part of the bed frame that does not move to prevent harm to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Viral infection:
Chronic stress can suppress the immune system, making individuals more susceptible to infections, including viral infections. Prolonged stress can dysregulate the immune response, leading to increased vulnerability to various illnesses.
B) Increased cognitive awareness:
Chronic stress often impairs cognitive function rather than enhancing it. It can lead to difficulties with concentration, memory problems, and cognitive fatigue due to the continuous activation of the body's stress response system.
C) Hypotension:
Chronic stress typically leads to increased blood pressure rather than hypotension. Stress activates the sympathetic nervous system, resulting in the release of stress hormones like cortisol and adrenaline, which can elevate blood pressure over time.
D) Increased energy:
While acute stress can trigger a temporary surge in energy due to the release of stress hormones, chronic stress often leads to fatigue and exhaustion. Prolonged activation of the stress response system can deplete energy reserves and disrupt sleep patterns, resulting in feelings of fatigue and lethargy.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}
Explanation
Potassium Levels: The postoperative potassium level for the client is 3.0 mEq/L, which falls below the normal range of 3.5 to 5 mEq/L. Potassium is a critical electrolyte necessary for the proper functioning of cardiac muscles. It plays a pivotal role in maintaining the electrical conductivity of the heart. Hypokalemia, or low potassium levels, can disrupt this electrical conductivity, leading to abnormal heart rhythms or arrhythmias. Arrhythmias can manifest as palpitations, irregular heartbeats, or more severe cardiac events, which can be life-threatening if not addressed promptly.
Importance of Potassium in Cardiac Function: Potassium is essential for the repolarization phase of the cardiac action potential. It helps in the return of the cell to its resting state after each heartbeat. A deficiency in potassium disrupts this balance, increasing the risk of erratic heartbeats and arrhythmias. Low potassium can prolong the QT interval on an electrocardiogram (ECG), which is a marker for potential arrhythmic events.
Clinical Implications: For a postoperative client, maintaining electrolyte balance is crucial. Surgery and anesthesia can affect fluid and electrolyte levels, making it essential to monitor and correct any imbalances. The decrease in potassium levels from 3.5 mEq/L preoperatively to 3.0 mEq/L postoperatively highlights a trend that must be addressed to prevent complications such as arrhythmias.
Preventative Measures: To mitigate the risk of arrhythmias, the healthcare team should consider interventions to correct the hypokalemia. This may include administering potassium supplements orally or intravenously, depending on the severity and clinical context. Continuous cardiac monitoring may also be warranted to detect and manage any emerging arrhythmic events promptly.
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