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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.
Choice B rationale
Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.
Choice C rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.
Choice D rationale
Fever is an objective finding. It can be measured by the nurse using a thermometer.
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Insulin glargine does not last for 3 to 6 hours. It is a long-acting insulin that has a duration of action up to 24 hours.
Choice B rationale
This is correct. Insulin glargine lasts for 18 to 24 hours. It is a long-acting insulin that provides a base level of insulin that keeps working for 24 hours or longer.
Choice C rationale
This is also correct. Insulin glargine lasts for 16 to 24 hours. It is a long-acting insulin that provides a base level of insulin that keeps working for 24 hours or longer.
Choice D rationale
Insulin glargine does not last for 6 to 10 hours. It is a long-acting insulin that has a duration of action up to 24 hours.
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