Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly?
A. The restraints are attached to the side rails of the client's bed.
The restraints should never be attached to the side rails of the bed. This can cause injury if the side rails are moved up or down. Instead, restraints should be attached to a part of the bed frame that does not move.
B. The nurse can insert three fingers under the secured restraint.
The nurse should be able to insert only two fingers under the secured restraint. If three fingers can be inserted, the restraint is too loose and may not effectively prevent the patient from harming themselves or others.
C. The restraints are secured with a quick-release knot.
Securing the restraints with a quick-release knot is correct because it allows for easy and rapid removal in case of an emergency.
D. The restraint's soft pad faces away from the client's skin.
The soft pad of the restraint should face the client’s skin to prevent skin irritation and injury. If the soft pad faces away from the skin, it can cause discomfort and potential harm.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice c. The restraints are secured with a quick-release knot.
Choice A rationale:
The restraints should never be attached to the side rails of the bed. This can cause injury if the side rails are moved up or down. Instead, restraints should be attached to a part of the bed frame that does not move.
Choice B rationale:
The nurse should be able to insert only two fingers under the secured restraint. If three fingers can be inserted, the restraint is too loose and may not effectively prevent the patient from harming themselves or others.
Choice C rationale:
Securing the restraints with a quick-release knot is correct because it allows for easy and rapid removal in case of an emergency.
Choice D rationale:
The soft pad of the restraint should face the client’s skin to prevent skin irritation and injury. If the soft pad faces away from the skin, it can cause discomfort and potential harm.
Similar Questions
A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
A. Clenched teeth
Clenched teeth are a sign of unrelieved pain and indicate that the client needs more analgesia from the PCA pump. Difficulty swallowing, constipation, and urinary retention are common side effects of opioids and do not necessarily indicate unrelieved pain.
B. Difficulty swallowing
C. Constipation
D. Urinary retention
Full Explanation
The correct answer is A.
Clenched teeth are a sign of unrelieved pain and indicate that the client needs more analgesia from the PCA pump. Difficulty swallowing, constipation, and urinary retention are common side effects of opioids and do not necessarily indicate unrelieved pain.
A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
A. I will have an identification band that matches the one my baby wears."
The mother and the baby should have matching identification bands to prevent abduction or mix-up.
B. I can remove my security band to give it to a family member."
The mother should not remove her security band, as this can compromise her identity and safety.
C. I can take my baby to the lobby to visit family."
The mother should not take her baby to the lobby or other public areas, as this can expose the baby to infection or harm.
D. "I will carry my baby to the nursery."
The mother should use a bassinet or crib to transport her baby to the nursery, as this can prevent falls or injuries.
Full Explanation
The mother and the baby should have matching identification bands to prevent abduction or mix-up.
The mother should not remove her security band, as this can compromise her identity and safety.
The mother should not take her baby to the lobby or other public areas, as this can expose the baby to infection or harm.
The mother should use a bassinet or crib to transport her baby to the nursery, as this can prevent falls or injuries.
A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?
A. Identify the client by using one identifier before giving the medication.
B. Document medication administration prior to administering medication.
C. Administer time-critical medication 60 min before or after the scheduled time.
D. Verify the medication three times with the medication administration record.
Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client. The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.
Full Explanation
The correct answer is D.
Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.
The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.