Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Ensure that the restraints are snug against the client's wrists.

Move the ties so the restraints are secured to the side rails.

Ensure that the knot can be quickly released.

Tie the knot with a double turn or square knot.

Answer and Explanation

The Correct Answer is C

A. Ensure that the restraints are snug against the client's wrists: Restraints should be snug enough to prevent injury but not so tight as to impair circulation. However, this does not address the safety concern related to the type of knot used.

B. Move the ties so the restraints are secured to the side rails: Restraints should never be tied to the side rails because this can cause injury if the rail moves or the client attempts to climb over it.

C. Ensure that the knot can be quickly released: Using a quick-release knot, such as a half bow or slip knot, is essential to ensure the nurse can rapidly remove the restraints in an emergency, such as sudden respiratory distress or circulatory compromise.

D. Tie the knot with a double turn or square knot: Square knots are secure but not quick to release. In contrast, safety guidelines recommend quick-release knots for client restraints to allow for prompt intervention.

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Correct Answer is C

Explanation

A. Furosemide: Furosemide is a diuretic used to reduce fluid overload in cirrhosis, especially in ascites. However, it does not address the elevated ammonia level or the client’s confusion, which are signs of hepatic encephalopathy requiring more specific treatment.

B. Intravenous (IV) human albumin: Albumin may be administered to maintain intravascular volume and reduce ascites, but it does not lower serum ammonia. It is supportive therapy, not the priority intervention for encephalopathy.

C. Lactulose: Lactulose is the treatment of choice because it decreases serum ammonia by promoting its excretion through the stool. It helps improve mental status in clients with hepatic encephalopathy and is the most important prescription in this scenario.

D. Loperamide: Loperamide reduces diarrhea by slowing bowel motility, but in this case, diarrhea is beneficial for eliminating ammonia with lactulose. Using loperamide could worsen encephalopathy by reducing ammonia clearance.

A. Ask the chaplain to discuss death issues with the client. B. Notify the family that treatments have been discontinued. C. Request a consultation with the hospital social worker. D. Arrange a meeting with the family, healthcare provider, and client.

Correct Answer is D

Explanation

A. Ask the chaplain to discuss death issues with the client: While spiritual support may be helpful, this does not address the client’s expressed conflict about continuing treatment to satisfy his family’s wishes.

B. Notify the family that treatments have been discontinued: The nurse cannot make the decision to discontinue treatments without the client’s and healthcare provider’s input. This would be outside the nurse’s scope of authority.

C. Request a consultation with the hospital social worker: Although a social worker can help with emotional support and end-of-life planning, the immediate concern is facilitating open communication between the client, family, and healthcare team about the client’s wishes.

D. Arrange a meeting with the family, healthcare provider, and client: This action supports the client’s autonomy and ensures his wishes are heard. It also promotes collaborative decision-making about continuing or stopping treatment, aligning care with the client’s goals and values.

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Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client verbalizes that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

Correct Answer is D

Explanation

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