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 C
Explanation
The most important intervention the nurse should take when administering these medications to the client is to assess the client’s pain level and administer the appropriate medication based on the level of pain.
Choice A is not the correct answer because administering all medications at the same time may not provide effective pain relief and could result in overmedication.
Choice B is not the correct answer because administering the medication with the highest dose first may not provide effective pain relief and could result in overmedication.
Choice D is not the correct answer because administering the medication with the longest duration of action first may not provide immediate pain relief.
Correct Answer is D
Explanation
Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client’s vital signs.
This includes checking the client’s blood pressure, pulse rate, respiratory rate, and temperature.
These measurements can provide important information about the client’s overall health status and can help the nurse determine if it is safe to proceed with the procedure.
Choice A is not correct because abdominal girth is not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice B is not correct because breath sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice C is not correct because bowel sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
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