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 B

Explanation

A. Reapply a sterile non-adhesive dressing: While maintaining a clean dressing is important to prevent further contamination, it does not address the underlying MRSA infection causing the wound to worsen.

B. Administer prescribed antibiotics: Prompt administration of antibiotics is the priority because the wound is infected with MRSA and is enlarging, indicating active infection that requires systemic treatment to prevent sepsis and promote healing.

C. Request a nutrition consult: Adequate nutrition supports wound healing, but it is a secondary intervention and does not immediately treat the infection or stop its progression.

D. Limit visitors to immediate family only: Limiting visitors may reduce infection risk to others, but it does not directly treat the MRSA infection or address the acute worsening of the wound.

A. Refer the caregiver to an audiologist. B. Explain to the caregiver this a normal finding. C. Discuss the importance of prophylactic antibiotics. D. Schedule the toddler for a tympanostomy procedure.

Correct Answer is B

Explanation

A. Refer the caregiver to an audiologist: Referral to an audiologist is indicated if there are concerns about hearing loss, not for normal anatomical variations of the eustachian tubes.

B. Explain to the caregiver this is a normal finding: In toddlers, the eustachian tubes are naturally shorter and more horizontal, which predisposes them to ear infections. Educating the caregiver about this normal anatomy helps them understand the cause without unnecessary concern.

C. Discuss the importance of prophylactic antibiotics: Routine prophylactic antibiotics are not recommended for preventing recurrent ear infections due to normal eustachian tube anatomy, as overuse can lead to resistance.

D. Schedule the toddler for a tympanostomy procedure: Tympanostomy tubes are only considered for children with recurrent or persistent otitis media with effusion causing hearing loss or complications, not for normal anatomical predisposition alone.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

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Explanation

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Correct Answer is B

Explanation

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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