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 D

Explanation

Choice D rationale

Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.

Choice A rationale

Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.

Choice B rationale

Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.

Choice C rationale

Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.

A. Use friction when washing the affected area. B. Use a new cosmetic pad with each limited application of makeup. C. Use an oil-based soap to wash affected areas daily. D. Express the larger comedones periodically.

Correct Answer is B

Explanation

Choice A rationale

Using friction when washing the affected area can irritate the skin and worsen acne. Gentle cleansing is recommended to avoid aggravating the condition.

Choice B rationale

Using a new cosmetic pad with each limited application of makeup helps prevent the spread of bacteria and reduces the risk of further clogging pores, which can exacerbate acne.

Choice C rationale

Using an oil-based soap can clog pores and worsen acne. Non-comedogenic, water-based cleansers are recommended for acne-prone skin.

Choice D rationale

Expressing larger comedones periodically can lead to skin damage and scarring. It is better to use appropriate acne treatments to manage comedones.

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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

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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.)