A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?

Apply mitten restraints to prevent the client from disconnecting their tube feeding.

Apply a vest restraint daily at bedtime to prevent nighttime wandering.

Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation.

Apply soft heel protectors bilaterally while client is in bed.

Answer and Explanation

The Correct Answer is B

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

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Correct Answer is ["B","D"]

Explanation

Rationale

The frequency and amount of urination indicates that the body in able to utilize glucose reducing glucosuria and osmotic diuresis.

The ability to tolerate oral intake also indicates an improvement in the client’s general health

Improvement in perception of pedal pulses indicates an improvement in the hydration status of the client.

A normal pulse rate and blood pressure is an indicator of optimal hydration status- an improvement from the severely dehydrated state.

The blood glucose levels is dropping indicating an improvement in the glycemic control

A. Titrate IV fluids to maintain urine output at 75 mL/hr. B. Administer an opioid pain medication, C. Change dressings over the entrance and exit wounds. D. Obtain an ECG

Correct Answer is D

Explanation

D. Obtaining an electrocardiogram (ECG) is the first action to take when managing a client with an electrical shock injury. Electrical shock injuries can cause cardiac dysrhythmias, including ventricular fibrillation or other life-threatening arrhythmias. Therefore, obtaining an ECG allows for prompt assessment of cardiac rhythm and identification of any dysrhythmias that may require immediate intervention.
A. While fluid resuscitation may be necessary in the management of electrical shock injuries to address hypovolemia and promote renal perfusion, titrating IV fluids to maintain a specific urine output is not the first action to take.
B. Pain management is important in the care of clients with electrical shock injuries, but it is not the first action to prioritize
C. Changing dressings over the entrance and exit wounds is important for wound care, but it is not the first action to take.

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A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D"]

Explanation

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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