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 D
Explanation
A back massage is a type of cutaneous stimulation that can help reduce pain by activating the gate control theory of pain. Cutaneous stimulation is a non-pharmacological intervention that can be delegated to unlicensed assistive personnel (UAP) or nursing assistive personnel (NAP) under the supervision of a registered nurse.
Choice A is wrong because assessing pain status requires critical thinking and clinical judgment, which are skills that only registered nurses have. Pain assessment is not a task that can be delegated to UAP/NAP.
Choice B is wrong because administering a placebo is a type of pharmacological intervention that involves giving a substance that has no therapeutic effect. Placebos are unethical and ineffective for pain management and should not be used by any health care provider.
Choice C is wrong because reviewing a pain diary involves evaluating the patient’s response to pain interventions and adjusting the plan of care accordingly. This is a complex task that requires nursing knowledge and skills and cannot be delegated to UAP/NAP.
Correct Answer is D
Explanation
temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min. This set of vital signs indicates that the client may have an infection or sepsis, which are potential complications of an open cholecystectomy. The client has a fever, tachycardia, tachypnea, and hypotension, which are signs of systemic inflammatory response syndrome (SIRS).
Choice A is wrong because it shows mild hypothermia, hypotension, and tachycardia, which could be due to dehydration or blood loss, but not necessarily infection.
Choice B is wrong because it shows a slight fever, normal blood pressure, and bradycardia, which could be due to pain or medication, but not infection.
Choice C is wrong because it shows a low-grade fever, normal blood pressure and pulse, and mild tachypnea, which could be due to inflammation or dehydration, but not infection.
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