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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Not taking diabetes medication when feeling sick could lead to uncontrolled blood sugar levels.
B. Having rapid-acting glucose readily available indicates understanding of the importance of managing hypoglycemic episodes.
C. While important, obtaining an A1C test annually is not directly related to managing acute hyperglycemia.
D. Using salt, herbs, and spices does not directly address blood glucose control.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
A. placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B. Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C. Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D. Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E. Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F. Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.
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