Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
Tie the knot with a double turn or square knot.
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.
The Correct Answer is D
Choice A: A double turn or square knot is not recommended because it is not a quick-release knot, which is necessary for patient safety in case of an emergency
Choice B: While restraints need to be secure, they should not be snug against the client's wrists. There should be enough space to fit two fingers between the restraint and the wrist to prevent circulation issues.
Choice C: Ties should not be secured to side rails as this can cause injury if the rails are moved. Instead, they should be attached to the movable part of the bed frame.
Choice D: This is the correct action. A half-bow knot is a type of quick-release knot, which is essential for the safety and quick release of the patient if needed
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Explaining the procedure and obtaining the signature is the provider’s responsibility, not the practical nurse’s.
B. Checking the medical record for a signed consent form is part of the practical nurse’s verification role but does not address assessing client understanding.
C. Obtaining consent from a family member is only appropriate if the client is unable to provide it; otherwise, consent must come directly from the client.
D. The practical nurse is responsible for ensuring the client understands the procedure and the purpose of the consent form, reinforcing the provider’s explanation and promoting informed consent.
Correct Answer is D
Explanation
d. “May I sit with you for a while?"
This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and offers companionship, which can help reduce isolation and loneliness.
The other options are not correct because:
- This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.
- This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.
- This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.
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