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.

Ensure that the knot can be quickly released.

Tie the knot with a double turn or square knot.

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

Answer and Explanation

The Correct Answer is B

A.   Restraints should be secure but not too tight to prevent injury or impaired circulation.
B.   Ensuring the knot can be quickly released is critical for the client's safety in case of emergency.
C.   A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk.
D.   Restraints should never be tied to side rails as this can cause injury if the rails are moved.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Uremic Encephalopathy: The client has chronic kidney disease and elevated blood urea nitrogen (BUN) levels, indicating impaired kidney function. Symptoms such as feeling tired, fever, and possibly altered mental status can be associated with uremic encephalopathy, a condition that arises from the accumulation of toxins in the blood due to kidney failure.

Fluid Volume Overload: The client has elevated blood pressure (140/86 mm Hg), an irregular and elevated heart rate (117 beats/minute), and respiratory rate (36 breaths/minute), which can be signs of fluid volume overload. Additionally, the slight bibasilar infiltrates observed in the chest X-ray suggest potential fluid accumulation in the lungs.

A. Promote active range-of-motion activities. B. Request that the provider prescribe a stool softener. C. Avoid gas-producing foods. D. Add fluid and fiber to the diet.

Correct Answer is D

Explanation

A. While physical activity is important for overall health, it may not directly address constipation. Increasing fluid and fiber intake is a more specific intervention.

B. Stool softeners can be helpful, but dietary modifications should be attempted first before resorting to medications.
C. Gas-producing foods may not be directly related to constipation. The focus should be on promoting regular bowel movements through diet and hydration.
D. Increasing fluid and fiber intake is a recommended first-line approach for managing constipation in older adults.

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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

Patient Data Exhibits After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic. Drag from Word Choices to complete the sentence. The nurse determines that the findings are reflective of and

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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