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 A

Explanation

Choice A rationale

Celecoxib, like other NSAIDs, can increase the risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Black, tarry stools can be a sign of GI bleeding.

Choice B rationale

Dry mouth is not typically associated with celecoxib use.

Choice C rationale

Polyuria, or excessive urination, is not typically associated with celecoxib use.

Choice D rationale

Bone pain is not typically a side effect of celecoxib. Celecoxib is used to relieve pain from various conditions, including osteoarthritis.

A. The patient needs a rubella vaccination after delivery. B. The patient is not currently infected with rubella. C. The patient is immune to the rubella virus. D. The patient requires a rubella vaccination at this time.

Correct Answer is A

Explanation

Choice A rationale

A negative rubella titer indicates that the patient does not have immunity to the rubella virus. Therefore, the patient would need a rubella vaccination after delivery to prevent future infection.

Choice B rationale

A negative rubella titer does not necessarily mean that the patient is not currently infected with rubella. It simply means that the patient does not have immunity to the virus.

Choice C rationale

A negative rubella titer indicates that the patient is not immune to the rubella virus, not that they are immune.

Choice D rationale

While the patient does need a rubella vaccination, it is not typically given during pregnancy due to the theoretical risk to the fetus. Instead, it is usually given after delivery.

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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

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Correct Answer is A

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Correct Answer is A

Explanation

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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?