A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Assess skin temperature and color before applying the restraints.

Ensure that the client's bed is in the lowest position.

Secure restraints to allow three fingers to slide under the restraints.

Pad bony prominences before applying the restraints.

Attach the client's restraints to the bed rail.

Answer and Explanation

Correct Answer : A,B,C,D

When planning care for a client who has a prescription for extremity restraints on both wrists, the nurse should assess the client's skin temperature and color before applying the restraints to ensure that there is no circulation impairment. The nurse should also ensure that the client's bed is in the lowest position to prevent falls. The restraints should be secured to allow three fingers to slide under them to prevent injury and ensure proper circulation. Bony prominences should be padded before applying the restraints to prevent pressure injuries.

Option e is incorrect because attaching the client's restraints to the bed rail can cause injury if the bed rail is moved or adjusted.

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Correct Answer is C

Explanation

If a client reports pain and informs the nurse that pain medications are not an option for managing their pain, the nurse can oﬀer non-pharmacological interventions such as a back massage to help relieve the client's pain. This is an appropriate response by the nurse.

a. Telling the client that the pain medication will work if they just give it a chance is not an appropriate response as it dismisses the client's concerns and preferences.

b. The nurse should not recommend that the client take any herbal remedies without first consulting with the healthcare provider.

d. Asking the client why they think pain medication is not going to help them may be appropriate in some situations, but it is not necessarily the best initial response. The nurse should first oﬀer non- pharmacological interventions to help relieve the client's pain.

A. Erythema along the path of the vein B. Coolness of the client's left forearm C. Pallor of the client's left forearm D. Pitting edema at the insertion site

Correct Answer is A

Explanation

The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inﬂammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inﬂamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.

Let's now discuss why the other

Options are not the correct answers:

Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood ﬂow to the area, such as arterial insufficiency, rather than inﬂammation of the vein.
Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood ﬂow or decreased oxygenation to the area, which can be caused by factors other than inﬂammation of the vein.
Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as ﬂuid overload or localized inﬂammation, and its presence does not necessarily confirm the presence of phlebitis.

In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inﬂammation of the vein, which can be caused by various factors including irritation or infection. The other

Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with diﬀerent underlying conditions or factors.

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A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a pain level of 5 on a scale from 0 to 10. The client informs the nurse that pain medications are not an Option for managing pain. Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

A nurse is monitoring a client who is receiving continuous IV ﬂuid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

Correct Answer is A

Explanation

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