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The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Complete an adverse occurrence/incident report.

Ensure that the restraints are not too tight.

Initiate the facility’s restraint flow sheet.

Demonstrate proper securing of the restraints.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Completing an adverse occurrence/incident report is important if an incident occurs, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice B rationale

Ensuring that the restraints are not too tight is important for the client’s safety and comfort, but it does not address the improper securing of the restraints to the bedside rails. The restraints should be secured to a movable part of the bed frame, not the rails.

Choice C rationale

Initiating the facility’s restraint flow sheet is necessary for documentation, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

Choice D rationale

Demonstrating proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.

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A. Assess strength of deep tendon reflexes. B. Determine apical pulse rate and rhythm. C. Observe color and amount of urine. D. Compare muscle strength bilaterally.

Correct Answer is B

Explanation

Choice A rationale

Assessing the strength of deep tendon reflexes is important in evaluating neuromuscular function, but it is not the most critical intervention for a client with hyperkalemia. Hyperkalemia primarily affects cardiac function, so monitoring the heart is crucial.

Choice B rationale

Determining the apical pulse rate and rhythm is the most important intervention for a client with a serum potassium level of 7.5 mEq/L. Hyperkalemia can cause life-threatening cardiac arrhythmias, and monitoring the heart rate and rhythm can help detect early signs of these complications.

Choice C rationale

Observing the color and amount of urine can provide information about kidney function and hydration status, but it is not the most critical intervention for hyperkalemia. The primary concern with hyperkalemia is its effect on the heart.

Choice D rationale

Comparing muscle strength bilaterally can help assess neuromuscular function, but it is not the most critical intervention for hyperkalemia. The focus should be on monitoring cardiac function to prevent life-threatening complications.

A. Insert a rectal tube at specified intervals. B. Assist to a bedside commode 30 minutes after meals. C. Encourage the use of incontinence briefs. D. Administer a glycerin suppository 15 minutes after meals.

Correct Answer is B

Explanation

Choice A rationale

Inserting a rectal tube at specified intervals is not a standard practice for bowel training regimens. This intervention is typically reserved for specific medical conditions and is not recommended for routine management of chronic fecal incontinence.

Choice B rationale

Assisting the client to a bedside commode 30 minutes after meals leverages the natural gastrocolic reflex, which stimulates bowel movements after eating. This intervention helps establish a regular bowel routine and is a key component of bowel retraining programs.

Choice C rationale

Encouraging the use of incontinence briefs does not address the underlying issue of bowel incontinence and may not help in establishing a regular bowel routine. This intervention is more focused on managing the symptoms rather than treating the condition.

Choice D rationale

Administering a glycerin suppository 15 minutes after meals can stimulate bowel movements, but it is not the first-line intervention for establishing a bowel training regimen. This approach may be used as an adjunct to other bowel retraining techniques.

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The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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Take full exam for free The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

Correct Answer is B

Explanation

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The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?