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 A
Explanation
A. Use an elevated toilet seat: Using an elevated toilet seat can help prevent excessive bending of the hip joint, reducing strain and potential dislocation risk after total hip replacement surgery.
B. Log rolling onto the operative side is contraindicated after total hip replacement surgery. This movement could place excessive stress on the newly replaced hip joint, increasing the risk of dislocation and complications.
C. Keeping the affected heel on the bed helps maintain proper alignment and precautions after total hip replacement surgery. It supports the hip joint and reduces the risk of dislocation by preventing excessive rotation or movement.
D. While some hip exercises are beneficial, internal and external rotation exercises are typically avoided immediately after total hip replacement surgery to prevent strain on the new joint.
Correct Answer is D
Explanation
D. Limiting the time that visitors spend with the client is a reasonable precaution to reduce their overall radiation exposure. Prolonged exposure to radiation can increase the risk of adverse effects. By limiting visitors to a specific time frame, the nurse can help control their exposure while still allowing for social support and companionship.
A. Discarding radioactive materials in regular trash cans can pose significant risks to sanitation workers, the environment, and public health.
B. Proper disposal of soiled linens contaminated with radioactive materials is essential to prevent radiation exposure to others. Soiled linens should be handled and disposed of according to institutional protocols for managing radioactive waste.
C. Maintaining a safe distance from the client is an important radiation safety precaution. However, this alone may not be sufficient to ensure adequate protection, depending on the specific circumstances of the treatment and the level of radiation emitted by the sources.
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