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 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.

A. Assess for flushed, warm skin regularly. B. Vary sites for temperature measurement. C. Document the client's circadian rhythms. D. Measure temperature at regular intervals.

Correct Answer is D

Explanation

D. To assess fever patterns accurately in a client with a fever of unknown origin, the nurse should measure the temperature at regular intervals. This helps in identifying trends and patterns in the fever, such as spikes at specific times of the day or consistent elevations. Regular temperature measurements provide valuable information for the healthcare team to diagnose and manage the underlying cause of the fever effectively.

A. Assessing for flushed, warm skin can be indicative of fever, due to vasodilation and skin flushing. While this assessment can provide subjective clues about the presence of fever, it does not provide comprehensive information about fever patterns over time.

B. Different sites may reflect variations in temperature due to local factors or differences in blood flow. However, while varying sites can contribute to a comprehensive assessment of body temperature, it does not specifically address the need to assess fever patterns over time.

C. While circadian rhythms can influence temperature variations, particularly in relation to sleep- wake cycles, documenting circadian rhythms alone does not provide specific information about fever patterns.

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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

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

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is D

Explanation

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