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
The goal of the care plan should be to help the client overcome his activity intolerance related to pain.
This can be achieved by helping him to ambulate without discomfort.
Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.
Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.
Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.
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.
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