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."
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Monitoring daily weight can help detect early signs of lithium toxicity, as sudden weight gain may indicate fluid retention, which is a concern with lithium treatment. It is important for clients to monitor their weight regularly to ensure no significant fluctuations occur that could suggest adverse effects⁴.
Choice B reason: Avoiding foods with high tyramine content is not specifically related to lithium therapy. This dietary restriction is more commonly associated with monoamine oxidase inhibitors (MAOIs), a different class of psychiatric medications. Lithium does not interact with tyramine in the same way⁴.
Choice C reason: Limiting daily fluid intake is not recommended for clients taking lithium unless otherwise directed by a healthcare provider. Adequate fluid intake is essential to prevent dehydration, which can increase lithium levels and the risk of toxicity. Clients should maintain a consistent intake of fluids unless they have a condition that requires fluid restriction⁴⁵.
Choice D reason: Following a low sodium diet is not advised for clients on lithium therapy. Lithium is processed in the body similarly to sodium, so if sodium levels are too low, lithium retention may increase, leading to toxicity. Clients should maintain a consistent, adequate intake of sodium to prevent fluctuations in lithium levels⁴.
Correct Answer is A
Explanation
Choice A reason : Anginal pain is commonly triggered by physical exertion or emotional stress, which increases the heart's demand for oxygen. When the narrowed coronary arteries cannot supply enough oxygen-rich blood to the heart muscle, angina occurs³⁷.
Choice B reason : While sitting up may help relieve discomfort for some conditions, anginal pain is typically relieved by resting or taking prescribed medication such as nitroglycerin, which helps to widen the blood vessels and improve blood flow to the heart muscle³⁶.
Choice C reason : This statement is incorrect. Anginal pain does not persist with rest and organic nitrates; these are actually the measures taken to alleviate the pain. Resting decreases the heart's demand for oxygen, and nitrates are effective in relieving anginal pain³.
Choice D reason : Typically, anginal pain does not last longer than a few minutes. If chest pain persists for more than 20 minutes, it may indicate a more serious condition, such as a heart attack, and immediate medical attention is required³.
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