A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

Contact the provider within 48 hr to obtain a prescription for the restraints.

Remove the restraints from the client's wrists every 2 hr.

Check that one finger will fit between the client's wrists and the restraints.

Fasten the restraints' ties to the bed's side rails.

Answer and Explanation

The Correct Answer is B

A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.

B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.

C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.

D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.

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Correct Answer is D

Explanation

A. Acetaminophen: Acetaminophen is an effective analgesic for mild to moderate pain but may not be sufficient for managing postoperative pain after a total knee arthroplasty, where moderate to severe pain is common.

B. Ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID. that can be used for pain, but it may not be the best choice for moderate to severe postoperative pain, as opioids are typically more effective for this type of pain.

C. Celecoxib: Celecoxib is an NSAID, and like ibuprofen, it can be useful for managing pain, but for a postoperative pain level of 6, a stronger medication like an opioid may be more appropriate.

D. Oxycodone: Oxycodone is an opioid analgesic, and it is typically used to manage moderate to severe pain, such as the pain a patient may experience after total knee arthroplasty. It would be the most appropriate choice for a pain level of 6 on a 0–10 scale.

A. "I am thankful I am done having children." B. "I should expect my periods to resume in 1 month." C. "I will have a large scar on my stomach after this procedure." D. "I will no longer need a regular gynecological examination."

Correct Answer is A

Explanation

A. "I am thankful I am done having children" is correct. This statement demonstrates the client's understanding of the procedure’s purpose, which is typically done to end the ability to conceive. The client is reflecting on a key aspect of the procedure, showing an informed decision about the surgery.

B. "I should expect my periods to resume in 1 month" is incorrect. A vaginal hysterectomy typically results in the permanent cessation of periods, so this statement indicates a lack of understanding of the procedure's effects.

C. "I will have a large scar on my stomach after this procedure" is incorrect. A vaginal hysterectomy is performed through the vaginal canal, and the client typically should not have a large abdominal scar. This statement may indicate a misunderstanding of the surgery's approach.

D. "I will no longer need a regular gynecological examination" is incorrect. While a vaginal hysterectomy removes the uterus, clients still need regular gynecological examinations, including Pap smears and other assessments, depending on their individual health needs. This statement reflects a misunderstanding of ongoing care requirements.

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A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client reports a pain level of 6 on a scale from 0 to 10. Which of the following medications should the nurse administer?

Correct Answer is D

Explanation

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

Correct Answer is A

Explanation

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