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.
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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Related Questions
Correct Answer is C
Explanation
C. It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
A. This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
D. While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.
Correct Answer is D
Explanation
A. Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.
C.While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.
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