Which measure should a nurse include in the care plan for a client who has mitt restraints to prevent pulling out tubes?
Removing the mitts when the client is asleep.
Performing range of motion exercises every two hours.
Tying the restraints securely around the wrists and to the bed.
Placing the restraints loosely to allow increased freedom of movement.
The Correct Answer is B
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Decreased flexibility is a normal age- related change that occurs in the elderly due to loss of elasticity in the ligaments and tendons.
Some possible explanations for the other choices are:
Choice B. Pain when standing. Pain when standing is not a normal finding and could indicate arthritis, osteoporosis, or injury.
Choice C. Swelling of the ankles. Swelling of the ankles is not a normal finding and could indicate heart failure, kidney disease, or venous insufficiency.
Choice D. Urinary incontinence. Urinary incontinence is not a normal finding and could indicate urinary tract infection, prostate enlargement, or neurological impairment.
Correct Answer is D
Explanation
A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.
The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.
Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.
Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.
Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.
Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.
Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.
Beta-blockers can lower blood pressure, heart rate, and cardiac output.
They are not indicated for hypovolemia and can worsen the client’s condition.
To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.
For example: “I am (name), the nurse caring for (client name) in room (number).
I am calling because I am concerned that the client has developed hypovolemia after surgery.”
Background: Provide relevant and brief information related to the situation.
For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.
Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”
Assessment: Share your analysis and considerations of options. For
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