The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly removed the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take?

Assess capillary refill distal to the restraints.

Verify that the restraints can be quickly released.

Replace the nasogastric tube.

Reinsert the peripheral IV catheter.

Answer and Explanation

The Correct Answer is B

B. When applying restraints, ensuring that they can be quickly released is essential for maintaining the safety and well-being of the client. This is especially important in cases where restraints are used to prevent harm or injury to the client, as they should only be used as a last resort and for the shortest duration necessary.

A. Checking capillary refill provides valuable information about peripheral perfusion and the adequacy of blood flow to the extremities. However, ensuring the restraints can be released easily is more crucial.

C. While replacing the nasogastric tube may be necessary if it has been removed, it's not the most immediate concern after applying wrist restraints. The priority is to ensure the safety and comfort of the patient with the restraints in place.

D. Reinserting the peripheral IV catheter may be necessary if it has been dislodged. However, it's not the most critical action immediately after applying wrist restraints.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

D. Neuropathy, especially when associated with numbness and tingling in the lower extremities, poses a significant risk for impaired skin integrity. The loss of sensation can lead to decreased awareness of pressure, friction, or trauma to the feet, making the client more susceptible to skin breakdown, ulcers, and injuries.

A. Increasing numbness and tingling in the lower extremities, which primarily suggests neuropathic symptoms rather than impaired mobility.

B. A self-care deficit may arise if the client's neuropathy significantly affects their ability to perform foot care tasks independently. However, self-care deficit becomes a priority concern.

C. Neuropathy can increase the risk of foot injuries due to decreased sensation, which in turn can lead to infections if not promptly addressed. However, while infection is a potential complication, the immediate concern in this scenario is preventing the development of skin breakdown and ulcers.

A. Positive external place. B. Motivational phrases. C. Emotional reflection. D. Tranquil sounds.

Correct Answer is A

Explanation

A. This technique involves creating vivid mental images of serene and calming environments, allowing the client to mentally escape from discomfort and focus on a peaceful setting. By immersing themselves in this imagined place, clients may experience relaxation and relief from pain.

B. Motivational phrases are statements or affirmations that inspire and encourage the client. While motivational phrases can be incorporated into guided imagery sessions to boost morale and foster positive thinking, they may not be as effective as focusing on a positive external place for managing chronic pain.

C. While emotional reflection can be an important aspect of holistic pain management, it may not be the primary focus during guided imagery sessions aimed at pain relief.

D. While soothing sounds can create a peaceful ambiance and contribute to stress reduction, they are often used as background elements rather than the primary focus of guided imagery for pain management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly removed the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is D

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)