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."

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason : Achieving a blood pressure of 120/80 is a general goal for overall cardiovascular health, but it is not specific to the management of heart failure. While controlling blood pressure is important in heart failure, the primary objective is to reduce the heart's workload¹.

Choice B reason : Reducing the workload on the heart is a key objective in managing heart failure. This can be achieved through medications that improve heart function, lifestyle changes, and sometimes surgical interventions. The goal is to improve the heart's efficiency and reduce symptoms such as shortness of breath and fatigue¹.

Choice C reason : Encouraging the client to walk briskly on a treadmill at 4 to 5 miles an hour may not be appropriate for all heart failure patients, especially without medical supervision. Exercise recommendations should be personalized based on the individual's condition and tolerance¹.

Choice D reason : While dietary modifications are part of heart failure management, completely eliminating all sodium and fat is not practical or recommended. Instead, a balanced diet with controlled sodium intake is advised to help manage fluid retention¹.

A. "A headache is an expected side effect of the medication." B. "A headache is an indication of an allergy to the medication." C. "A headache is likely due to the anxiety about the chest pain." D. "A headache indicates tolerance to the medication."

Correct Answer is A

Explanation

Choice A reason : Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, which can cause blood vessels to expand, leading to headaches. Patients should be informed that this is a common reaction and can be managed with over-the-counter pain relievers if necessary¹²³⁴.

Choice B reason : A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions would more likely present with symptoms such as rash, itching, or difficulty breathing.

Choice C reason : While anxiety can cause headaches, in this context, the headache is more likely a direct side effect of the nitroglycerin, especially since it occurred after taking the medication and the chest pain was relieved.

Choice D reason : Tolerance to medication refers to a reduced response to a drug over time, requiring higher doses to achieve the same effect. A headache after taking nitroglycerin does not indicate tolerance; it is a known side effect of the drug.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been diagnosed with heart failure. One of the main overall objectives of the management of heart failure is which of the following?

Correct Answer is B

Explanation

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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