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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Free Nursing Study Resources

Correct Answer is B,D,E,C,A

Explanation

The correct order of Erikson’s stages of psychosocial development from birth to adolescence is:

Trust vs. mistrust
Autonomy vs. shame and doubt
Initiative vs. guilt
Industry vs. inferiority
Identity vs. role confusion

A. Avoid using warm water to wash the patient’s face. B. Apply an eye patch to the patient’s right eye. C. Provide range-of-motion exercises to the patient’s neck and shoulders. D. Place suction equipment at the patient’s bedside.

Correct Answer is D

Explanation

Choice A rationale

Avoiding warm water to wash the patient’s face is not typically necessary for a patient with a right-sided acoustic neuroma.

Choice B rationale

Applying an eye patch to the patient’s right eye is not typically necessary unless the patient is experiencing double vision, which is not a common symptom of acoustic neuroma.

Choice C rationale

Providing range-of-motion exercises to the patient’s neck and shoulders is not typically necessary for a patient with a right-sided acoustic neuroma.

Choice D rationale

Placing suction equipment at the patient’s bedside can be helpful if the patient is experiencing difficulty swallowing or has a risk of aspiration due to impairment of cranial nerves IX and X111213.

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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 has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson’s stages of psychosocial development in order from birth to adolescence.

Correct Answer is B,D,E,C,A

Explanation

A nurse is caring for a patient who has a right-sided acoustic neuroma, resulting in impairment of cranial nerves IX andX. Which of the following interventions should the nurse implement?

Correct Answer is D

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?

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?