A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Evaluate the need for the client to remain in mitten restraints.

Assist the client with range-of-motion exercises of the hands.

Instruct the client's family about the purpose of mitten restraints.

Determine the circulation status of the affected extremities every 2 hr

Answer and Explanation

The Correct Answer is B

Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.

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Correct Answer is D

Explanation

Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.

The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.

During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.

The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.

A. Encourage the client to use the overbed trapeze. B. Maintain abduction of the client's residual limb with a pillow. C. Caution the client to avoid a prone position while in bed. D. Keep a loose, absorbent dressing over the client's surgical site

Correct Answer is A

Explanation

A nurse caring for a client who is 2 days postoperative following an above-the-knee amputation should encourage the client to use the overbed trapeze. This will promote independence and mobility by allowing the client to reposition themselves in bed and perform upper body exercises.

Maintaining abduction of the client's residual limb with a pillow can help prevent contractures, but it does not directly promote mobility.

Cautioning the client to avoid a prone position while in bed is appropriate to prevent pressure injuries and promote healing, but it also does not directly promote mobility.

Keeping a loose, absorbent dressing over the client's surgical site is important for infection control but does not promote mobility.

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A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Correct Answer is D

Explanation

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

Correct Answer is A

Explanation

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A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

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