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

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. 28%:

When a client receives oxygen via a nasal cannula at a flow rate of 2 L/min, the approximate inspired oxygen concentration is around 24-28%. This is because each liter of oxygen delivered through a nasal cannula adds approximately 4% to the baseline room air concentration of 21%. Therefore, at 2 L/min, the client would be receiving approximately 24-28% inspired oxygen concentration.

A. 36%, B. 70%, C. 50%:

These percentages are not consistent with the oxygen concentration delivered via a nasal cannula at 2 L/min. Higher flow rates or alternative oxygen delivery systems, such as masks or high-flow nasal cannula, would be needed to achieve these concentrations.

A. Functional incontinence B. Stress incontinence C. Urinary retention D. Fecal incontinence

Correct Answer is B

Explanation

A. Functional incontinence: Functional incontinence occurs when a person has difficulty reaching the toilet due to physical or cognitive impairments, such as mobility issues or dementia. Kegel exercises, which focus on strengthening the pelvic floor muscles, would not directly address the underlying causes of functional incontinence.

B. Stress incontinence: Stress incontinence is characterized by the involuntary leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, laughing, or exercising. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help support the bladder and reduce the occurrence of stress incontinence.

C. Urinary retention: Urinary retention refers to the inability to empty the bladder completely. While Kegel exercises may help improve bladder control, they are not typically used to address urinary retention, which often requires other interventions such as medications, catheterization, or surgery.

D. Fecal incontinence: Fecal incontinence involves the involuntary leakage of stool. Kegel exercises are not effective for addressing fecal incontinence, as they primarily target the pelvic floor muscles involved in urinary control, not bowel control. Treatment for fecal incontinence may include dietary modifications, medications, pelvic floor rehabilitation, or surgical interventions, depending on the underlying cause.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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