After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.
At checking the restraints, which action is most important for the nurse to take?

Reinsert the peripheral IV catheter.

Verify that the restraints can be quickly released.

Assess capillary refill distal to the restraints.

Replace the nasogastric tube.

Answer and Explanation

The Correct Answer is C

When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.

This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.

Choice A, reinserting the peripheral IV catheter, may be necessary but is not the most important action in this situation.

Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.

Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.

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Correct Answer is ["4"]

Explanation

The client has been prescribed a one-time dose of metronidazole 2 grams by mouth.

Since 1 gram is equal to 1000 milligrams (mg), 2 grams is equal to 2000 mg.

The medication is available in 500 mg tablets, so the nurse should administer 2000 mg / 500 mg/tablet = 4 tablets.

A. Basilar lung sounds that are diminished in the left lung. B. Contraction of the left pupil when light shines in the right eye. C. Capillary refill of 2 seconds in the lower right foot. D. Active bowel sounds in the lower right quadrant.

Correct Answer is A

Explanation

Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.

In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”

Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.

Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.

Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.

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After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube. At checking the restraints, which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for a one-time dose of metronidazole 2 grams by mouth. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numerical value only).

Correct Answer is ["4"]

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is A

Explanation

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After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.
At checking the restraints, which action is most important for the nurse to take?