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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
30 to 40 mL/hour. This is the normal range of urine output for a typical adult client. The urine output should be at least 0.5 mL/kg/hour for adults.
Assuming an average weight of 70 kg, this would be 35 mL/hour.
Choice A is wrong because 5 to 10 mL/hour is too low and indicates oliguria, which is a sign of inadequate kidney function or dehydration.
Choice B is wrong because 12 to 15 mL/hour is also below the normal range and may indicate oliguria.
Choice C is wrong because 16 to 25 mL/hour is slightly below the normal range and may indicate reduced kidney perfusion or fluid intake.
Correct Answer is A
Explanation
A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”. This client may have a dehiscence or separation of the surgical wound, which is a serious complication that requires immediate attention.
The nurse should evaluate this client first and notify the surgeon.
Choice B is wrong because bile-colored fluid draining from a nasogastric tube is an expected finding after abdominal surgery and does not indicate an urgent problem.
The nurse should monitor the client’s fluid and electrolyte balance and provide antiemetics as needed.
Choice C is wrong because a three-day postoperative client who has an ileostomy and reports the need to have a bowel movement may have a paralytic ileus or a temporary cessation of bowel motility. This is a common postoperative complication that usually resolves within 72 hours.
The nurse should assess the client’s bowel sounds, abdominal distension, and ostomy output and encourage early mobilization and oral intake as tolerated.
Choice D is wrong because a three-day postoperative client who is receiving intravenous antibiotics for a wound infection may have a surgical site infection or an infection that occurs within 30 days of surgery. This is a preventable complication that can be managed with antibiotics, wound care, and infection control measures.
The nurse should monitor the client’s vital signs, wound appearance, and laboratory values and educate the client on signs and symptoms of infection.
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