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 D

Explanation

Choice A rationale

Phenytoin is an antiepileptic medication used to control seizures. It’s important for the patient to understand that they should not switch brands of this medication without consulting their healthcare provider. Different brands of phenytoin can have different effects, and switching could potentially lead to changes in seizure control.

Choice B rationale

Regular dental appointments are important for patients taking phenytoin. This medication can cause gum overgrowth (gingival hyperplasia), so good oral hygiene and regular dental check- ups are essential.

Choice C rationale

It’s crucial for patients to notify their doctor before taking any other medications. Phenytoin can interact with many other drugs, altering their effectiveness or increasing side effects.

Therefore, the patient’s statement indicates an understanding of the need for caution when considering additional medications.

Choice D rationale

Phenytoin is a long-term medication for controlling seizures. It’s not something that patients can stop taking once they feel better. Abruptly stopping the medication can lead to withdrawal

seizures. Therefore, the patient’s statement, “I’ll be glad when I can stop taking this medicine,” indicates a need for further teaching about the importance of continuing the medication as prescribed.

A. Decreased phosphate level B. Decreased potassium level C. Decreased chloride level D. Decreased sodium level

Correct Answer is B

Explanation

Choice A rationale

Phosphate levels are not directly affected by spironolactone. Spironolactone is a potassium- sparing diuretic and does not typically affect phosphate levels.

Choice B rationale

Decreased potassium level is not typically expected in a patient taking spironolactone. Spironolactone is a potassium-sparing diuretic, meaning it can actually lead to increased potassium levels. However, in the context of liver failure and ascites, other factors may influence potassium levels.

Choice C rationale

Chloride levels are not directly affected by spironolactone. Spironolactone primarily affects the balance of potassium and sodium in the body.

Choice D rationale

Sodium levels could potentially be decreased in a patient taking spironolactone, as it can cause the body to lose sodium. However, in the context of liver failure and ascites, sodium levels are often carefully managed.

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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 conducting discharge teaching for a patient who has seizures and a new prescription for phenytoin. Which statements by the patient indicate a need for further teaching?

Correct Answer is D

Explanation

A nurse is analyzing the lab results of a patient with liver failure and ascites who is on spironolactone. What lab findings should the nurse anticipate?

Correct Answer is B

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?