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 B

Explanation

This response acknowledges the client's fear and invites them to express their concerns, allowing the nurse to address them effectively and provide necessary information or support.
A. This response focuses specifically on the fear of needles and may not address the client's overall apprehension about the procedure or their specific concerns.
C. This response directly asks the client to articulate their fears, which can help the nurse understand the specific reasons behind their anxiety and tailor their support and education accordingly.
D. While this response attempts to offer reassurance, it may come across as dismissive of the client's current fears and may not effectively address their concerns or provide the support they need before undergoing the procedure.

A. Massage the client's legs every 4 hr while they are awake. B. Encourage the client to perform circumduction of the feet. C. Limit the client's fluid intake to 2,000 mL daily. D. Keep the client's knees in a flexed position while they are in bed.

Correct Answer is B

Explanation

Feet circumduction increases the activity of calf muscles aiding in venous return. This prevents pooling of blood the deep venous system and hence lowers the risk of DVT

A, C and D have no role in the prevention of DVT

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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?

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