A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube.
Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Provide diversionary activities for the client.

Assist the client with toileting at frequent intervals.

Involve the family in the client’s care.

Explain to the client that he will be restrained if he does not stop pulling on his NG tube.

Use an electronic bed alarm device.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.

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Correct Answer is C

Explanation

Choice A rationale

Fever usually accompanies myocardial infarction. This statement is incorrect. While fever can occur with myocardial infarction, it is not a common or primary symptom. Acetaminophen is not prescribed for this reason.

Choice B rationale

Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does. This statement is correct but not the reason for prescribing acetaminophen before nitrates. Acetaminophen is chosen for its analgesic properties without affecting platelet function.

Choice C rationale

Headache is a common side effect of nitrates. This statement is correct. Nitrates can cause vasodilation, leading to headaches. Acetaminophen is prescribed to manage this common side effect.

Choice D rationale

Acetaminophen potentiates the therapeutic effect of nitrates. This statement is incorrect. Acetaminophen does not enhance the therapeutic effects of nitrates; it is used to manage side effects like headaches.

A. 9 percent. B. 18 percent. C. 36 percent. D. 54 percent.

Correct Answer is B

Explanation

Choice A rationale

9 percent is the percentage of total body surface area (TBSA) for one arm (front or back) or the head and neck combined. Since the burns are on the front and back of both arms, this percentage is too low.

Choice B rationale

18 percent is the correct percentage of TBSA for burns on the front and back of both arms. Each arm accounts for 9 percent of TBSA, so both arms together account for 18 percent.

Choice C rationale

36 percent is the percentage of TBSA for burns on both legs (front and back) or the entire trunk (anterior and posterior). This percentage is too high for burns on the front and back of both arms.

Choice D rationale

54 percent is the percentage of TBSA for burns on the entire trunk (anterior and posterior) and one leg (front and back). This percentage is too high for burns on the front and back of both arms.

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A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?

Correct Answer is B

Explanation

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A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube.
Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)