The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly removed the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take?

Assess capillary refill distal to the restraints.

Verify that the restraints can be quickly released.

Replace the nasogastric tube.

Reinsert the peripheral IV catheter.

Answer and Explanation

The Correct Answer is B

B. When applying restraints, ensuring that they can be quickly released is essential for maintaining the safety and well-being of the client. This is especially important in cases where restraints are used to prevent harm or injury to the client, as they should only be used as a last resort and for the shortest duration necessary.

A. Checking capillary refill provides valuable information about peripheral perfusion and the adequacy of blood flow to the extremities. However, ensuring the restraints can be released easily is more crucial.

C. While replacing the nasogastric tube may be necessary if it has been removed, it's not the most immediate concern after applying wrist restraints. The priority is to ensure the safety and comfort of the patient with the restraints in place.

D. Reinserting the peripheral IV catheter may be necessary if it has been dislodged. However, it's not the most critical action immediately after applying wrist restraints.

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Correct Answer is C

Explanation

Restarting the IV line first ensures that the client has immediate access to intravenous fluids and medications, which is critical for maintaining hydration and treatment continuity. This is especially important if the client is receiving antibiotics or other medications that need to be administered continuously or urgently.

Following the IV line, performing tracheostomy care ensures that the airway is maintained and free from obstructions. This is essential, especially in clients with compromised respiratory function. By addressing the airway next, the nurse ensures that the client can breathe effectively and is stable.

Changing the coccyx dressing is important for wound management, especially with an infected wound. Performing this last minimizes the risk of contaminating the sterile field or the dressing while the nurse is managing other tasks. This also reduces the number of times the nurse enters and exits the room, adhering to contact isolation protocols.

A. On dorsal surfaces. B. Over the heels. C. Around the ankles. D. Between the toes.

Correct Answer is D

Explanation

D. Thoroughly drying between the toes is essential for preventing moisture buildup, which can contribute to the development of fungal infections such as athlete's foot. In a client with diminished circulation in the lower extremities, ensuring proper drying between the toes becomes even more critical to reduce the risk of skin breakdown and infection.

A, B, C- drying the dorsum, heels and ankle regions is important to prevent maceration of skin but they are not the areas commonly affected by infection in cases of compromised circulation.

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The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly removed the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take?

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Naxlex Comprehensive Predictor Exams

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

Correct Answer is C

Explanation

The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

Correct Answer is D

Explanation

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

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The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

The nurse has a prescription for bilateral soft wrist restraints for an older adult client who has repeatedly removed the nasogastric (NG) tube and IV catheters. After applying the restraints, which action is most important for the nurse to take?

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