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 A

Explanation

A. 74-year-old female with malnutrition and a foley catheter in place:

Malnutrition can weaken the immune system, making the individual more susceptible to infections. Additionally, the presence of a foley catheter increases the risk of urinary tract infections.

B. 54-year-old female admitted for chest pain observation:

Chest pain observation does not inherently increase the risk of infection.

C. 34-year-old male admitted for seizure observation:

Seizure observation does not inherently increase the risk of infection.

D. 78-year-old male with right-sided hemiplegia following a stroke:

While the hemiplegia following a stroke may pose mobility challenges, the presence of malnutrition and a foley catheter in option A puts the patient at a higher risk for infection.

A. Use standard precautions in caring for all clients B. Place all post-surgical clients in contact isolation C. Order IV antibiotics for all clients with sacral pressure wounds D. Limit visitations to 2 people a day for each client

Correct Answer is A

Explanation

A. Use standard precautions in caring for all clients:

Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.

B. Place all post-surgical clients in contact isolation:

Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.

C. Order IV antibiotics for all clients with sacral pressure wounds:

Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.

D. Limit visitations to 2 people a day for each client:

While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.

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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

The nurse would recognize which of the following patients would be at highest risk for developing an infection?

Correct Answer is A

Explanation

Which of the following interventions would best assist the nurse in breaking the chain of infection for all clients?

Correct Answer is A

Explanation

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