A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?

Apply mitten restraints to prevent the client from disconnecting their tube feeding.

Apply a vest restraint daily at bedtime to prevent nighttime wandering.

Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation.

Apply soft heel protectors bilaterally while client is in bed.

Answer and Explanation

The Correct Answer is B

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

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Correct Answer is D

Explanation

D. The primary purpose of maintaining an elastic bandage around the residual limb after a below-the- knee amputation is to provide compression and support, which helps minimize swelling (edema) of the residual limb. By reducing edema, the elastic bandage can promote proper wound healing, improve comfort, and facilitate the fitting of prosthetic devices in the future.
A. While maintaining proper wound care and hygiene can help prevent wound infections, an elastic bandage around the residual limb of a below-the-knee amputation primarily serves other purposes, such as providing compression and support, rather than directly preventing wound infections.
B. The purpose of an elastic bandage is not to conceal the surgical site. It is used primarily for compression, support, and minimizing swelling of the residual limb.
C. While an elastic bandage may help provide some pressure and support to the surgical site, its primary purpose is not to prevent sutures from loosening.

A. Hypertension B. 2+ edema C. Crackles in lungs D. Tachycardia

Correct Answer is D

Explanation

D. Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
A. Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.

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A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

Correct Answer is D

Explanation

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