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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Chest pain radiating to the left arm is characteristic for angina in coronary artery disease. This is suggested more by the client’s medical history of hypertension, hyperlipidemia and type 2 diabetes mellitus.
Clients with angina are scheduled for diagnostic cardiac catheterization to assess the extent of coronary blockage
Heparin is used to prevent the propagation of a clot that is formed on an unstable atherosclerotic plaque. Beta blockers are prescribed to lower the heart rate. This reduces the myocardial demand for oxygen.
The firstline medication include antiplatelets unless there's concurrent venous thromboembolism.
Keeping the client NPO within 2 hours of the procedure is important to prevent aspiration whole under sedation.
Ambulation increases demand on the heart which may worsen the pain Antibiotics have no role in coronary artery disease.
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.
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