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

The correct answer is Choice A

Choice A rationale: Serum iron levels in children typically range from 50 to 120 mcg/dL. A value of 38 mcg/dL is significantly below the lower limit, indicating possible iron deficiency. Iron is essential for hemoglobin synthesis, oxygen transport, and cognitive development. Deficiency can lead to microcytic anemia, fatigue, and developmental delays. Early detection is critical, especially in pediatric populations where growth and neurodevelopment are rapid. This abnormal value warrants prompt provider notification for further evaluation and intervention.

Choice B rationale: Normal red blood cell (RBC) count in children ranges from approximately 4.1 to 5.5 million/mm³. A value of 4.9 million/mm³ falls comfortably within this range and does not suggest anemia or polycythemia. RBC count reflects bone marrow function and oxygen-carrying capacity. In the absence of symptoms or abnormal hemoglobin levels, this value is considered physiologically appropriate and does not require provider notification. It supports adequate erythropoiesis and oxygenation in the pediatric patient.

Choice C rationale: White blood cell (WBC) count in children typically ranges from 5,000 to 10,000 cells/mm³. A value of 10,000 cells/mm³ is at the upper limit of normal and may reflect mild physiological variation, such as recent activity or minor stress. It does not indicate infection, inflammation, or hematologic disorder unless accompanied by clinical symptoms or abnormal differential counts. Therefore, this value is not considered pathologic and does not require immediate reporting to the provider.

Choice D rationale: Blood lead levels below 5 mcg/dL are considered acceptable by CDC standards, although no level is truly safe. A value of 2 mcg/dL is within the expected range and does not indicate acute toxicity or environmental exposure requiring intervention. Lead affects neurological development, but levels under 5 mcg/dL are generally monitored without urgent action. Continued surveillance and environmental precautions are advised, but this value does not necessitate immediate provider notification.

A. The patient’s blood pressure is 80/56 mm Hg. B. The patient reports lower extremity weakness. C. The patient’s temperature is 38.2°C (100.8 F). D. The patient reports severe itching.

Correct Answer is A

Explanation

Choice A rationale

The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.

Choice B rationale

Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.

Choice C rationale

A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.

Choice D rationale

Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.

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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?

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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?