a nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints which of following actions should the nurse
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Nursing Elites

ATI RN

ATI Leadership Practice A

1. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Correct answer: C

Rationale: When applying wrist restraints, it is crucial to secure the restraint ties to the bed's side rails to ensure the client's safety and prevent injury. Padding the client's wrists (Choice A) is not a standard practice and may compromise the effectiveness of the restraints. Evaluating the client's circulation (Choice B) is important but should be done more frequently than every 8 hours to ensure prompt detection of any circulation issues. Removing the restraints every 4 hours (Choice D) is unnecessary and may increase the risk of injury or agitation in the client.

2. There are several pitfalls that should be avoided when using social media of any type. For example, a nurse or student could be found guilty of libel in which of the following scenarios?

Correct answer: D

Rationale: Statements about individuals encountered in one�s professional or educational life that could damage that person�s reputation may be slander or libel and can be prosecuted as quasi-intentional torts.

3. For a 55-year-old female patient with type 2 diabetes and a nursing diagnosis of imbalanced nutrition: more than body requirements, which goal is most important?

Correct answer: A

Rationale: The most important goal for a 55-year-old female patient with type 2 diabetes and imbalanced nutrition due to more than body requirements is to reach a glycosylated hemoglobin level of less than 7%. This goal directly addresses the management of diabetes and is crucial in preventing complications associated with high blood sugar levels. Choice B focuses on weight loss, which may be beneficial but is not as critical as controlling blood sugar levels. Choice C, distributing calories throughout the day, is important for glycemic control but not as immediate as reaching a target HbA1c level. Choice D, stating the reasons for eliminating simple sugars, is a good educational goal but not as urgent as achieving glycemic control.

4. Which action by a patient indicates that the home health nurse�s teaching about glargine and regular insulin has been successful?

Correct answer: D

Rationale:

5. In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?

Correct answer: B

Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. When a client has a latex allergy, it is crucial to avoid direct contact with latex-containing products to prevent an allergic reaction. Choosing hypoallergenic latex gloves that are powder-free reduces the risk of the client being exposed to latex allergens. Option A is incorrect because using ethylene oxide for sterilization does not directly address the client's latex allergy. Option C is incorrect because cleansing latex ports with chlorhexidine does not eliminate the risk of latex exposure. Option D is incorrect as it does not specifically address the issue of latex allergy during the procedure.

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