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
Acute laryngotracheobronchitis, also known as croup, is a common childhood condition that is usually caused by a viral infection. The main symptom is a distinctive barking cough. A cool mist tent can help to soothe the inflamed airways and reduce stridor, which is a high-pitched,
wheezing sound caused by disrupted airflow. Therefore, decreased stridor would indicate that the treatment has been effective.
Choice B rationale
While a decreased temperature might indicate a resolution of any underlying infection, it is not directly related to the effectiveness of a cool mist tent in treating acute laryngotracheobronchitis.
Choice C rationale
A barking cough is a symptom of acute laryngotracheobronchitis and does not indicate treatment effectiveness.
Choice D rationale
Improved hydration is important but is not a direct indicator of the effectiveness of the cool mist tent.
Correct Answer is C
Explanation
Choice A rationale
Swabbing an area of skin away from the wound to identify the usual flora is not the correct action. This would not provide a representative sample of the wound infection.
Choice B rationale
Irrigating the wound with an antiseptic prior to obtaining the specimen is not the correct action. This could potentially alter the results of the culture.
Choice C rationale
Cleansing the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen is the correct action. This helps to remove surface bacteria and ensures a more accurate culture result.
Choice D rationale
Including intact skin at the wound edges in the culture is not the correct action. This could contaminate the specimen with bacteria that are not part of the wound infection.
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