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 A

Explanation

Choice A rationale

Confusion or disorientation can be a normal part of the dying process. As the body systems start to shut down, changes in mental status, including confusion, can occur.

Choice B rationale

Sundowning is a phenomenon that is typically associated with dementia, particularly Alzheimer’s disease, and is characterized by confusion and agitation that gets worse in the late afternoon and evening. It is not specifically associated with the dying process.

Choice C rationale

While anxiety can occur at any stage of illness, it is not the most appropriate response in this context. The family member is specifically asking about confusion, not anxiety.

Choice D rationale

Needing more rest could be a part of the dying process, but it does not directly address the family member’s concern about confusion.

A. Monitor the toddler’s vital signs closely. B. Administer supplemental oxygen. C. Notify the healthcare provider. D. Reassess the toddler in 15 minutes.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is explaining the early stage of the dying process to a patient’s family. A family member mentions, “My parent seems really confused at times.”. What is the most appropriate response from the nurse?

Correct Answer is A

Explanation

A nurse is caring for a toddler.The nurse’s observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next?

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?