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.

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Correct Answer is B

Explanation

B. When the oxygen saturation is lower than expected, the nurse's first action should be to verify the accuracy of the reading by ensuring the proper placement and functioning of the pulse oximeter. This involves checking that the pulse oximeter probe is securely attached to the client's finger or other appropriate site and that there are no obstructions or interference affecting the reading.

A. A non-rebreather mask delivers higher concentrations of oxygen compared to a nasal cannula and is typically used when a client requires higher levels of oxygen supplementation. However, switching to a non-rebreather mask may not be appropriate without further assessment.

C. Increasing the oxygen flow rate to 3 L/minute would deliver a higher concentration of oxygen to the client, potentially improving oxygen saturation. However, increasing the oxygen flow should be done cautiously and based on clinical assessment to avoid oxygen toxicity.

D. Removing the nasal cannula would deprive the client of supplemental oxygen, which may not be appropriate if the client's oxygen saturation is already low. Oxygen supplementation is typically provided to improve oxygenation and support vital organ function.

A. When the client voided following catheter removal. B. Time of the last dose of IV antibiotic administration. C. Color of the urine during the catheter removal. D. Intake and output reports for the previous shift.

Correct Answer is A

Explanation

A. Delayed or inability to void after catheter removal could indicate urinary retention, which may require further intervention such as bladder scanning, straight catheterization, or reinsertion of a urinary catheter.

B. This is important for assessing the timing of antibiotic therapy but may not be directly related to the client's ability to void after catheter removal.

C. Color of the urine during catheter removal may provide information about the client's urinary status, but it does not confirm whether the client was able to void effectively after catheter removal.

D. Intake and output reports for the previous shift is relevant for assessing fluid balance and urinary output trends but does not specifically address the client's ability to void after catheter removal.

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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 who is postoperative and receiving supplemental oxygen at 2 L/minute via masal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Correct Answer is B

Explanation

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

Correct Answer is A

Explanation

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