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 D

Explanation

A. Placing the nurse's feet close together side by side to have a good center of gravity:

While maintaining a good center of gravity is important, in a falling situation, it's crucial to prioritize the client's safety over the nurse's stability. This option doesn’t address the prevention of the client’s fall.

B. Rocking the nurse's pelvis out and trying to hold the patient up to prevent falling:

Attempting to hold the patient up during a fall may put both the nurse and the client at risk of injury.

C. Grasping the gait belt and pushing the client’s body backward away from the nurse's body:

Pushing the client backward could cause the client to lose balance and fall in an uncontrolled manner.

D. Using the patient's gait belt to gently slide the client down the nurse's body to the floor:

This is the recommended action as it allows for a controlled descent to the floor, minimizing the impact of the fall and reducing the risk of injury to both the client and the nurse.

A. Pulse B. Temperature C. Blood Pressure D. Respirations

Correct Answer is C

Explanation

A. Pulse:

A pulse rate of 88 bpm is within the normal range. While it's important to monitor the pulse for changes, the reported pulse rate does not raise immediate concerns.

B. Temperature:

An oral temperature of 99.2 degrees Fahrenheit is within the normal range. While it's slightly elevated, it might be influenced by various factors, and isolated temperature readings are not as urgent as other vital signs.

C. Blood Pressure:

A blood pressure reading of 178/112 mm Hg is significantly elevated. High blood pressure is a major concern due to the potential risks it poses to the cardiovascular system, kidneys, and other organs. Immediate attention and further assessment are needed.

D. Respirations:

Respiratory rate of 18 bpm is within the normal range. While it's important to monitor respiratory rate, the reported rate does not raise immediate concerns.

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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

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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