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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Gently pull the auricle up and back before instilling the drops. This technique straightens the auditory canal and allows the drops to reach the eardrum.
It also prevents contamination of the ear canal by the finger.
Choice A is wrong because pulling the auditory canal down and toward the front is the proper method for children, not adults.
This technique is used for children because their auditory canal is shorter and more curved than adults.
Choice C is wrong because lowering the head and taking a deep breath during the instillation has no effect on the administration of otic drops.
It may also cause discomfort or dizziness for the client.
Choice D is wrong because wearing sterile gloves and inserting one finger in the canal is unnecessary and potentially harmful.
It may introduce bacteria or damage the ear canal or eardrum.
Correct Answer is A
Explanation
A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.
The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.
Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.
Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.
The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.
Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.
Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.
The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.
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