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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Protect the muscles of the lower extremities from atrophy:
This statement is not the primary purpose of sequential compression devices (SCDs) and compression stockings. While these devices can help maintain muscle tone by promoting blood circulation, their primary function is to prevent blood pooling and reduce the risk of deep vein thrombosis (DVT).
B. Keep the blood from pooling in lower extremities to avoid clots:
This is the correct purpose of sequential compression devices and compression stockings. They are designed to promote venous return and prevent blood from pooling in the lower extremities, thereby reducing the risk of blood clots, especially in individuals at risk for deep vein thrombosis (DVT).
C. Keep the patient from getting sores on the skin:
Preventing sores on the skin is not the primary purpose of these devices. While improved circulation may contribute to skin health, preventing skin sores is not the primary therapeutic goal of SCDs and compression stockings.
D. Keep the patient’s joints in working order:
Maintaining joint function is not the primary purpose of sequential compression devices and compression stockings. These devices primarily focus on promoting venous circulation and preventing complications related to blood pooling and clot formation.
Correct Answer is D
Explanation
A. Every four hours:
Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.
B. Every hour:
Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.
C. Every shift:
Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.
D. Every two hours:
Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.
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