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 C
Explanation
An abnormal absolute neutrophil count in a preschooler should be reported to the healthcare provider immediately. Neutrophils are a type of white blood cell that play a key role in the body’s immune response. An abnormal count could indicate an infection, inflammation, or other serious health conditions.
Correct Answer is A
Explanation
Choice A rationale
Spending time with the patient is a therapeutic nursing approach when caring for a patient hospitalized for the treatment of severe depression. This approach shows the patient that they
are not alone and that their feelings are important. It can help build trust and rapport, which are essential for effective therapeutic communication and intervention.
Choice B rationale
Offering the patient choices of activities can be beneficial as it can provide a sense of control and improve mood. However, this approach should be used judiciously as the patient’s energy levels and interest in activities may be low due to depression.
Choice C rationale
Establishing a therapeutic relationship with the patient is an important aspect of care. However, this is a broad approach and involves more than just spending time with the patient. It includes building trust, maintaining confidentiality, and providing empathetic and nonjudgmental care.
Choice D rationale
Exploring the truth of the patient’s statements can be part of cognitive behavioral therapy (CBT), a common treatment for depression. However, this is usually done by a trained therapist and not by a nurse providing general care.
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