The nurse is applying a wrist restraint on a client who has pulled out his IV multiple times. How should the nurse secure this device?

Tie it to the bed frame with a quick release knot

Strap the restraint with a square knot to the head of the bed

Use a quick release knot to tie the restraint to the side rail

Assist with range of motion at least every 3 hours

Answer and Explanation

The Correct Answer is A

A. Tie it to the bed frame with a quick release knot. This option is correct because securing the restraint to the bed frame ensures that the client cannot easily remove it, while a quick release knot allows for rapid removal in case of an emergency.

B. Strap the restraint with a square knot to the head of the bed.While a square knot may be secure, it is not considered a quick-release method, which is essential for the safety of the client.

C. Use a quick release knot to tie the restraint to the side rail. Tying a restraint to the side rail can pose a risk because if the side rail is lowered, it may create a situation where the restraint is loose or ineffective. It is safer to secure it to the bed frame instead.

D. Assist with range of motion at least every 3 hours. While providing range of motion is important to prevent complications from immobility, it does not address how to secure the restraint itself. Regular assessments and range of motion exercises should be part of the overall care plan but are not directly related to securing the restraint.

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Correct Answer is C

Explanation

A. Comatose:

A comatose state is characterized by an unarousable and unresponsive condition. Individuals in a coma do not respond to external stimuli, including shaking or calling their name.

B. Stuporous:

Stupor is a state of near-unconsciousness or insensibility. A stuporous patient may require more intense stimulation to achieve a response than someone who is lethargic.

C. Lethargic:

Lethargy is a state of drowsiness or fatigue. Lethargic patients may appear drowsy but can be awakened by gentle stimulation, such as shaking and calling their name.

D. Awake and Alert:

An awake and alert state implies full responsiveness, awareness, and orientation to the environment. The patient in the scenario does not fit this description.

A. Perform oral hygiene at least every 2 hours. B. Client must be supine with head of bed below 30 degrees. C. Use alcohol-based mouth rinse with oral swab. D. Assist the client with oral care by brushing their teeth twice daily

Correct Answer is A

Explanation

A. Perform oral hygiene at least every 2 hours:

Regular oral care is essential to maintain oral health, prevent infections, and provide comfort. When a client is NPO, and especially if they are weak or drowsy, the nurse should perform oral care at least every 2 hours to keep the oral cavity moist, reduce the risk of infection, and provide comfort.

B. Client must be supine with the head of the bed below 30 degrees:

Keeping the head of the bed elevated to at least 30 degrees is important for preventing aspiration and promoting respiratory function. This position is not specific to oral care but is a general guideline for managing clients at risk for aspiration.

C. Use alcohol-based mouth rinse with oral swab:

Alcohol-based mouth rinses can be drying and may not be suitable for a client who is NPO, as they might contribute to further dryness of the oral mucosa. Non-alcohol-based mouth rinses or moistened oral swabs are often preferred.

D. Assist the client with oral care by brushing their teeth twice daily:

While regular oral care is important, the frequency of twice daily brushing may not be sufficient for a weak, drowsy client, especially if they are NPO. Oral care should be performed more frequently to maintain oral hygiene.

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The nurse is applying a wrist restraint on a client who has pulled out his IV multiple times. How should the nurse secure this device?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

Correct Answer is A

Explanation

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