When using wrist restraints, which of these statements is correct?

Apply them safely and secure to the bed rails.

Use to protect elderly patients from pulling out tubes and lines as soon as you place them.

Apply them to clients who have a history of violence or a previous fall for everyone’s protection.

Use them only as a last resort after attempting alternatives and get an order to do so.

Answer and Explanation

The Correct Answer is D

Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.

Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.

This prevents the person from getting entangled or injured by the restraints.

Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.

Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.

Normal ranges for restraints are:

Check the person at least every 15 minutes
Remove restraints and meet basic needs at least every 2 hours
Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist

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Correct Answer is C

Explanation

Determining whether chest pain has been relieved. This is because nitroglycerin is a medication that is used to treat chest pain caused by cardiac origin or acute pulmonary edema. The main action of nitroglycerin is to relax and dilate the blood vessels, which reduces the workload of the heart and improves blood flow to the heart muscle.

Therefore, the most important nursing action after administering nitroglycerin sublingually is to assess if the chest pain has subsided or not.

Choice A is wrong because monitoring the client’s respiratory rate and effort is not the most important action after giving nitroglycerin. Although nitroglycerin can cause hypotension and bradycardia, which may affect the respiratory status, these are side effects that can be managed and are not life-threatening as chest pain.

Choice B is wrong because warning the client to lie still to prevent a headache is not a priority after giving nitroglycerin. Nitroglycerin can cause headache as a side effect, but this can be treated with analgesics and does not require the client to lie still. Moreover, lying still may increase the risk of venous thromboembolism in a client with peripheral vascular disease.

Choice D is wrong because verifying that the sublingual tablet produced a tingling sensation is not essential after giving nitroglycerin.

Although some sublingual tablets may produce a tingling sensation, this is not a reliable indicator of the drug’s effectiveness

A. The client speaks in a low voice. B. The client refuses to answer questions. C. The client responds inappropriately to questions. D. The client looks away from persons while speaking.

Correct Answer is C

Explanation

This is because responding inappropriately to questions can indicate that the client has difficulty hearing or understanding what is being asked. According to, hearing loss makes communication with the outside world difficult, and can result in new or exaggerated symptoms that are mistakenly attributed to cognitive decline.

Choice A is wrong because speaking in a low voice does not necessarily imply hearing loss. It could be due to other factors such as shyness, anxiety, or vocal cord problems.

Choice B is wrong because refusing to answer questions does not necessarily imply hearing loss.

It could be due to other factors such as lack of interest, defiance, or distrust.

Choice D is wrong because looking away from persons while speaking does not necessarily imply hearing loss.

It could be due to other factors such as cultural norms, eye contact avoidance, or distraction.

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When using wrist restraints, which of these statements is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action is most important after administering nitroglycerin sublingually?

Correct Answer is C

Explanation

Which client behavior is indicative of hearing loss?

Correct Answer is C

Explanation

A nurse is assessing a client with pain. What is the best question for the nurse to ask the client about the quality of pain?

Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

A client makes minimal eye contact with others and remains alone in their room during the day. Which question is an important consideration when planning the client’s care?

A client who is taking warfarin has an international normalized ratio (INR) of 0.8. Which question should a nurse ask to further evaluate the client?

A client is prescribed olanzapine for schizophrenia. How will the nurse monitor the client for adverse side effects? (Select all that apply).

A nurse is reviewing a medication reconciliation for an 80-year-old client with renal disease. Which medication should the nurse be most concerned about?

A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations. What is the priority action?

A client with severe bronchial pneumonia has been receiving oxygen, respiratory treatments, antibiotics, and intravenous fluids. Which arterial blood gas result would indicate that the treatment has been effective?