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.
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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.
This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.
Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.
Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.
Correct Answer is C
Explanation
This response shows that the nurse is willing to listen and provide support to the client.
It also allows the client to decide if they want to talk and share their feelings.
Choice A is not correct because it is not the most therapeutic response.
While it does encourage the client to talk about their visit with their significant other, it does not show that the nurse is willing to listen and provide support.
Choice B is not correct because it is not the most therapeutic response.
While it does acknowledge that the client may be feeling lonely, it does not show that the nurse is willing to listen and provide support.
Choice D is not correct because it is not the most therapeutic response.
While it does encourage the client to talk about their visit, it does not show that the nurse is willing to listen and provide support.
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