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","C","D","E"]

Explanation

Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determine its antibiotic susceptibility, guiding appropriate treatment.

C. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess for signs of infection and the body's immune response to the MRSA infection.

D. Use standard precautions and wear a mask.

Standard precautions should always be followed to prevent the transmission of infections in healthcare settings. Wearing a mask may be indicated if there is a risk of respiratory droplet transmission during wound care or other procedures.

E. Institute contact precautions for staff and visitors.

Contact precautions should be implemented to prevent the spread of MRSA to others. This includes wearing gloves and gowns when providing care, as well as educating staff and visitors about proper hand hygiene and infection control measures.

A. On dorsal surfaces. B. Over the heels. C. Around the ankles. D. Between the toes.

Correct Answer is D

Explanation

D. Thoroughly drying between the toes is essential for preventing moisture buildup, which can contribute to the development of fungal infections such as athlete's foot. In a client with diminished circulation in the lower extremities, ensuring proper drying between the toes becomes even more critical to reduce the risk of skin breakdown and infection.

A, B, C- drying the dorsum, heels and ankle regions is important to prevent maceration of skin but they are not the areas commonly affected by infection in cases of compromised circulation.

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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?

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Naxlex Comprehensive Predictor Exams

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin- resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

Correct Answer is D

Explanation

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