After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.
At checking the restraints, which action is most important for the nurse to take?
Reinsert the peripheral IV catheter.
Verify that the restraints can be quickly released.
Assess capillary refill distal to the restraints.
Replace the nasogastric tube.
The Correct Answer is C
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The priority intervention for a patient with persistent STIs and risky behaviors is to recommend consistent use of latex condoms.
According to the USPSTF, behavioral counseling is recommended for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs)1.
This includes providing information on common STIs and STI transmission, aiming to increase motivation or commitment to safer sex practices, and providing training in condom use1.
Choice B is not the answer because annual infection screening is important but not the priority intervention.
Choice C is not the answer because while it’s true that some infections may have no initial symptoms, this is not a priority intervention.
Choice D is not the answer because while advising that alcohol intake may lead to risky behaviors is important, it’s not the priority intervention.
Correct Answer is B
Explanation
If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.
Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.
Therefore, the nurse should obtain the respiratory rate first.
Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.
Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.
Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.
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