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 {"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.
Correct Answer is A
Explanation
A) Cheyne-Stokes respirations:
Cheyne-Stokes respirations are characterized by a cycle of gradually increasing and then decreasing respirations followed by a period of apnea. This pattern repeats in a regular cycle. It is commonly observed in clients with conditions affecting the central nervous system, such as traumatic brain injury, stroke, or brain tumors. Cheyne-Stokes respirations can also occur during the dying process. The alternating periods of hyperventilation and apnea result from fluctuations in oxygen and carbon dioxide levels in the blood.
B) Kussmaul respirations:
Kussmaul respirations are deep, rapid, and labored breathing patterns often observed in clients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.
C) Apneustic respirations:
Apneustic respirations are characterized by prolonged inspiratory gasps followed by insufficient expiration. This irregular breathing pattern typically indicates damage to the pons, a part of the brainstem involved in regulating breathing. Apneustic respirations are different from the pattern described in the scenario.
D) Stridor:
Stridor is a high-pitched, noisy respiratory sound heard on inspiration that indicates upper airway obstruction, such as from swelling, foreign body aspiration, or tumors. It is not associated with the alternating pattern of hyperventilation and apnea described in Cheyne-Stokes respirations.
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