A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?
"I will call the doctor and get a prescription."
"I will cover the catheter so he cannot see it."
"I will provide more stimulation in his environment."
"Let's wait until tonight to see if he continues this behavior."
The Correct Answer is B
Choice A reason : While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.
Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.
Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.
Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Implementing seizure precautions is necessary for a child with bacterial meningitis due to the increased risk of seizures associated with the condition.
Choice B reason : Placing the client in a semi-Fowler's position can help reduce intracranial pressure and facilitate breathing, which is beneficial for a child with meningitis.
Choice C reason : Admitting the client to a private room is important to prevent the spread of infection and provide a quiet environment to reduce the risk of seizures and other complications.
Choice D reason : Measuring head circumference every shift is not typically necessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants whose skull bones have not yet fused.
Correct Answer is A
Explanation
Choice A reason : A sore throat is a common side effect of radiation therapy to the neck area, particularly for cancer of the larynx. The radiation can cause inflammation and irritation of the throat and laryngeal tissues, leading to pain and discomfort when swallowing¹⁵. This side effect can be managed with pain relief medications and dietary adjustments to include softer foods and liquids.
Choice B reason : Dry mouth, or xerostomia, occurs when radiation damages the salivary glands, reducing saliva production. This can lead to difficulties in speaking, tasting, chewing, and swallowing, as well as an increased risk of dental problems¹³. Patients undergoing radiation therapy are often advised to stay hydrated and may be prescribed saliva substitutes or stimulants.
Choice C reason : Radiation to the neck might damage the thyroid gland, leading to hypothyroidism. Symptoms of thyroid problems due to radiation can include fatigue, weight gain, feeling cold, and having dry skin or hair³. Regular monitoring of thyroid function is recommended for patients who have received radiation therapy in the neck area.
Choice D reason : Lymphedema is swelling that can occur when radiation therapy affects the lymph nodes and vessels, impeding the flow of lymph fluid. In the context of neck radiation, this can lead to swelling in the neck and face³. Management includes physical therapy, compression garments, and careful skin care to prevent infection.
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