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 B
Explanation
The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain.
Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system1.
Therefore, the nurse should document the finding as neuropathic pain.
Choice A is not correct because acute pain is a general term that does not specify the type of pain experienced by the patient.
Choice C is not correct because visceral pain refers to pain that originates from internal organs.
Choice D is not correct because nociceptive pain refers to pain caused by tissue damage or injury.
Correct Answer is B
Explanation
Pressure redistribution is an important part of preventing and treating pressure sores1.
Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.
Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.
Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure
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