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 B
Explanation
To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.
Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.
Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.
Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.
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.
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