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 A
Explanation
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
Correct Answer is D
Explanation
The question asks how many milligrams of the medication will be in 1 mL of D5W. To find this, we need to know the concentration of the medication in the solution.
Concentration is the amount of medication per unit volume of solution. We can use this formula:
Concentration = Mass / Volume
We know that 250 mg of the medication is diluted in 500 mL of D5W. So we can plug these values into the formula:
Concentration = 250 mg / 500 mL Simplifying, we get:
Concentration = 0.5 mg / mL
This means that there are 0.5 mg of the medication in every 1 mL of D5W. So the answer is
- To check our answer, we can use another formula:
Mass = Concentration x Volume
If we want to find the mass of the medication in 1 mL of D5W, we can multiply the concentration by the volume:
Mass = 0.5 mg / mL x 1 mL Simplifying, we get:
Mass = 0.5 mg
This matches our answer.
The other choices are wrong because they do not use the correct formula or values. Here is why:
Choice A is wrong because it uses the inverse of the concentration (1 / 0.5) instead of the concentration (0.5).
Choice B is wrong because it uses the mass of the medication (250 mg) instead of the concentration (0.5 mg / mL).
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