A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

"I will call the doctor and get a prescription."

"I will cover the catheter so he cannot see it."

"I will provide more stimulation in his environment."

"Let's wait until tonight to see if he continues this behavior."

Answer and Explanation

The Correct Answer is B

Choice A reason : While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.

Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.

Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.

Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.

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Correct Answer is C

Explanation

Choice A reason : Methadone is an opioid used primarily for opioid maintenance therapy and to relieve severe pain, not typically for alcohol withdrawal. It does not address the specific symptoms associated with alcohol withdrawal such as seizures or delirium tremens¹.

Choice B reason : Salicylates, such as aspirin, are not used to treat alcohol withdrawal. They can increase the risk of bleeding, especially in the gastrointestinal tract, which can be a concern in individuals with a history of heavy alcohol use¹.

Choice C reason : Benzodiazepines, such as chlordiazepoxide, are the first-line treatment for alcohol withdrawal. They help reduce the risk of seizures, ease withdrawal symptoms, and can prevent the progression to more severe forms of withdrawal such as delirium tremens¹².

Choice D reason : Diphenhydramine is an antihistamine with sedative properties, but it is not a first-line medication for alcohol withdrawal. While it may provide some sedation, it does not prevent seizures or other serious complications of alcohol withdrawal¹.

A. The provider will be coming to explain the situation. B. "I reported the incident to my supervisor who decided to contact the authorities." C. "As a nurse, I am required by law to report suspected child abuse." D. "I am unable to discuss this, but I can contact my supervisor to speak with you."

Correct Answer is C

Explanation

Choice A reason : While it is true that a healthcare provider may come to explain the situation, this response does not directly address the parent's concern about the reason for the nurse's action. It is important for the nurse to communicate clearly and directly about their responsibilities and the actions they have taken.

Choice B reason : This response indicates that the nurse has taken action by reporting to a supervisor, but it does not clarify the nurse's legal obligation to report suspected child abuse. It is essential for nurses to understand and communicate their role as mandated reporters to ensure transparency and trust in the healthcare setting¹.

Choice C reason : This is the most appropriate response because it directly addresses the parent's question and explains the nurse's legal responsibility. Nurses are mandated reporters and are legally required to report any suspicions of child abuse to protect the child's welfare. This response is clear, direct, and upholds the nurse's professional and legal obligations¹³.

Choice D reason : While contacting a supervisor may be part of the protocol, this response does not provide the parent with an explanation for the nurse's action. It is important for the nurse to explain their legal duty to report suspected child abuse, which is the primary reason for their action.

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A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

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