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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.
Choice B rationale
Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.
Choice C rationale
Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.
Choice D rationale
Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.
Correct Answer is A
Explanation
Choice A rationale
A negative rubella titer indicates that the patient does not have immunity to the rubella virus. Therefore, the patient would need a rubella vaccination after delivery to prevent future infection.
Choice B rationale
A negative rubella titer does not necessarily mean that the patient is not currently infected with rubella. It simply means that the patient does not have immunity to the virus.
Choice C rationale
A negative rubella titer indicates that the patient is not immune to the rubella virus, not that they are immune.
Choice D rationale
While the patient does need a rubella vaccination, it is not typically given during pregnancy due to the theoretical risk to the fetus. Instead, it is usually given after delivery.
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