A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints.
What should the nurse’s response be?

I will call the doctor and get a prescription.

I will cover the catheter so he can’t see it.

Let’s wait until tonight to see if he continues this behavior.

I will apply the restraints immediately.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While it is within the nurse’s scope of practice to communicate with the doctor regarding the patient’s condition, applying restraints should not be the first course of action when a patient frequently tries to remove their IV catheter. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

Choice B rationale

This is the correct response. Covering the catheter so the patient can’t see it may help to reduce the patient’s urge to remove it. This is a non-invasive intervention that respects the patient’s autonomy while also ensuring their safety.

Choice C rationale

Waiting until nighttime to see if the patient continues the behavior may not be the best course of action. If the patient is frequently trying to remove their IV catheter, it is important to address the issue promptly to prevent potential harm.

Choice D rationale

Applying restraints immediately is not the best course of action. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

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Correct Answer is B

Explanation

Choice A rationale

While swelling in the legs can be a side effect of some medications, it is not a measure of the effectiveness of sertraline. Sertraline is an antidepressant, and its effectiveness would be measured by improvements in mood and behavior.

Choice B rationale

An improvement in mood is a key indicator that the sertraline is effective. Sertraline is a selective serotonin reuptake inhibitor (SSRI) used to treat depression and other mood disorders. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance.

Choice C rationale

While it’s important to monitor blood pressure in patients taking any medication, a blood pressure within the expected range is not specifically an indication of the effectiveness of sertraline.

Choice D rationale

Weight loss is not a primary indicator of the effectiveness of sertraline. While some patients may experience weight changes while taking this medication, it is not a measure of its effectiveness in treating depression or other mood disorders.

A. Drink a full glass of water after taking the medication. B. Limit sodium intake. C. Consume the medication alongside dairy products to enhance absorption. D. Reduce dietary fiber to counteract the potential side effect of diarrhea.

Correct Answer is A

Explanation

Choice A rationale

Drinking a full glass of water after taking the medication is a good practice when taking calcium carbonate antacids. This helps to ensure that the medication is fully swallowed and reaches the stomach, where it can neutralize stomach acid.

Choice B rationale

Limiting sodium intake is not directly related to the use of calcium carbonate antacids. While a low-sodium diet may be recommended for other health reasons, it is not a specific recommendation for patients taking this medication.

Choice C rationale

Consuming the medication alongside dairy products to enhance absorption is not recommended. Calcium carbonate antacids can interact with dairy products, potentially leading to an excessive intake of calcium.

Choice D rationale

Reducing dietary fiber to counteract the potential side effect of diarrhea is not a typical recommendation for patients taking calcium carbonate antacids. While calcium carbonate can cause constipation in some people, it does not typically cause diarrhea.

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A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints.What should the nurse’s response be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient who has been taking sertraline for 2 weeks.Which finding should the nurse identify as an indication that the medication is effective?

Correct Answer is B

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Correct Answer is A

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A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints.
What should the nurse’s response be?