Which measure should a nurse include in the care plan for a client who has mitt restraints to prevent pulling out tubes?
Removing the mitts when the client is asleep.
Performing range of motion exercises every two hours.
Tying the restraints securely around the wrists and to the bed.
Placing the restraints loosely to allow increased freedom of movement.
The Correct Answer is B
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
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Related Questions
Correct Answer is D
Explanation
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis and may not meet the client’s elimination needs.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis and may not be necessary unless the client has nausea or vomiting.
Choice C is wrong because providing oral care every four hours is not enough to prevent dehydration and dry mouth in a client who has been diaphoretic for the past six hours. The client may need more frequent oral care and fluid intake.
Correct Answer is C
Explanation
On a regular schedule around the clock. This is because when pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis.
Choice A is wrong because waiting for the client to exhibit physiologic symptoms of pain may delay the administration of analgesics and cause unnecessary suffering. Physiologic symptoms of pain are not always reliable indicators of pain intensity or quality.
Choice B is wrong because administering analgesics prior to painful activities may not provide adequate pain relief throughout the day. Painful activities may vary depending on the client’s condition and preferences.
Choice D is wrong because relying on the client’s request may not ensure optimal pain management. Some clients may be reluctant to ask for analgesics due to fear of addiction, side effects, or being perceived as weak.
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