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 A

Explanation

A. Strawberries aretypically associated with cross-reactivity with latex
B. Eggs are not commonly associated with cross-reactivity with latex.
C. Peanuts are not typically associated with cross-reactivity with latex. Peanut allergy involves specific proteins found in peanuts and is unrelated to latex allergy.

D Shellfish is not associated with cross-sensitivity with latex

A. Move the client up and down in bed by holding onto the halo traction device. B. Ensure that there is space for one finger to fit between the vest and the client's skin. C. Apply medicated powder under the vest to reduce itching. D. Loosen or tighten the screws on the device as needed for the client's comfort.

Correct Answer is B

Explanation

B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.

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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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