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. 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.

A. Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair. B. Obtain a quad cane for the client to use as a transfer aid. C. Position a friction-reducing sheet under the client. D. Have the client sit on the side of the bed for several minutes before moving to the chair.

Correct Answer is D

Explanation

A. Infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair:

Administering an IV fluid bolus before transferring the client to a chair is not necessary and not directly related to the safe transfer from bed to chair. It doesn't directly assist with the physical transfer process.

B. Obtaining a quad cane for the client to use as a transfer aid:

While a quad cane can be helpful for some individuals with mobility issues, it might not be necessary for the initial transfer from bed to chair and may not be appropriate for everyone.

C. Positioning a friction-reducing sheet under the client:

While a friction-reducing sheet can assist with moving a client, it may not be necessary for the initial transfer from bed to chair, especially if the client can bear weight and perform the transfer safely.

D. Having the client sit on the side of the bed for several minutes before moving to the chair:

This is the best action. Allowing the client to sit on the side of the bed for a few minutes helps the body adjust to being in a sitting position after an extended period of lying down. It allows for gradual adaptation and reduces the risk of dizziness or orthostatic hypotension when moving from lying down to sitting up.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?

Correct Answer is D

Explanation

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