A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints.
What should the nurse’s response be?

I will call the doctor and get a prescription.

I will cover the catheter so he can’t see it.

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

I will apply the restraints immediately.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While it is within the nurse’s scope of practice to communicate with the doctor regarding the patient’s condition, applying restraints should not be the first course of action when a patient frequently tries to remove their IV catheter. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

Choice B rationale

This is the correct response. Covering the catheter so the patient can’t see it may help to reduce the patient’s urge to remove it. This is a non-invasive intervention that respects the patient’s autonomy while also ensuring their safety.

Choice C rationale

Waiting until nighttime to see if the patient continues the behavior may not be the best course of action. If the patient is frequently trying to remove their IV catheter, it is important to address the issue promptly to prevent potential harm.

Choice D rationale

Applying restraints immediately is not the best course of action. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

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Correct Answer is B

Explanation

Choice A rationale

Cleaning the inside of the container with a wipe is not recommended. The container provided for a urine sample is sterile, and cleaning it could introduce bacteria, contaminating the sample.

Choice B rationale

The statement “I will urinate a little then stop” is correct. This is part of the process of collecting a midstream urine sample. The initial stream of urine can contain bacteria from the urethra or genital area, so it’s recommended to start urinating, then stop and collect the sample midstream.

Choice C rationale

The statement “I will use each cleansing wipe twice” is incorrect. Each cleansing wipe should only be used once to avoid reintroducing bacteria.

Choice D rationale

The statement “I will use the cleansing wipe from front to back” is correct. This is the proper way to clean the genital area to avoid introducing bacteria from the anal area into the urethra.

A. “Have you experienced any nausea or vomiting with your headache?” B. “Are the lights in this room bothering you?” C. “Have you noticed any confusion or clouded thinking?” D. “Did you feel weak before the headache started or do you feel weak now?”

Correct Answer is A

Explanation

Choice A rationale

Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help in assessing the severity of the migraine and planning appropriate interventions.

Choice B rationale

Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.

Choice C rationale

While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.

Choice D rationale

Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.

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A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints.What should the nurse’s response be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a female client on how to collect a midstream urine sample. Which statement from the client indicates they understand the procedure?

Correct Answer is B

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Correct Answer is A

Explanation

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A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints.
What should the nurse’s response be?