Nokea
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Tie the belt restraint to the side rail of the bed.
- C. Check the client's skin integrity every 4 hr.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown protects skin and ensures comfort.
You may also like to solve these questions
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Use your incentive spirometer.
- B. Dangle your legs over the side of the bed.
- C. Perform regular isometric ejercicios.
- D. Increase your intake of protein.
Correct Answer: B
Rationale: Dangling legs allows gradual blood pressure adjustment, preventing orthostatic hypotension.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Make sure two fingers fit under the restraints.
- C. Check the client's range of motion every 6 hr.
- D. Secure the restraints with a square knot.
Correct Answer: B
Rationale: Two fingers ensure the restraints are secure but not too tight.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Tighten the abdominal muscles.
- B. Bend at the waist.
- C. Keep legs straight.
- D. Hold object away from the body.
Correct Answer: A
Rationale: Tightening abdominal muscles stabilizes the core, reducing back strain.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: B
Rationale: Opioids slow bowel motility, increasing constipation risk.