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 C

Explanation

Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.

Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.

Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.

Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.

A. Providing physical demonstration. B. Using simulation activities. C. Incorporating verbal analogies. D. Offering positive reinforcement.

Correct Answer is B

Explanation

Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences .

Choice A is not the answer because providing a physical demonstration may be helpful in teaching a skill, but it does not actively engage the clients in problem-solving .

Choice C is not the answer because incorporating verbal analogies can help clients understand concepts, but it does not actively engage them in problem-solving .

Choice D is not the answer because offering positive reinforcement can encourage and motivate clients, but it does not actively engage them in problem-solving .

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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 is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections. Which intervention is most appropriate to prevent the spread of MRSA to others?

Correct Answer is C

Explanation

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which of the following is most useful for the nurse to include?

Correct Answer is B

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?

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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?