The nurse is caring for a client who has pulled out his IV twice. The nurse has replaced the IV in the left hand, and the physician has ordered restraints for the client
Which of the following restraints would meet the legal restraint requirements for this client? 1. A leather restraint on the right hand
2. Soft four-point restraints
3. A jacket restraint
4. An elbow restraint on the right arm
4
Rationale 1: The elbow restraint on the right arm would prevent the client from bending the arm to pull the IV out of the left hand. The client's movements are minimally restricted, which is a major requirement of restraints. A jacket restraint would not prevent the client from pulling out his IV and four-point restraints would be more than is needed for this client. Leather restraints are only used for the criminal or very violent client who requires very strong restraints.
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The nursing instructor is talking about caring for patients with feeding tubes and endotracheal tubes (ET)
The instructor tells the students that before each tube feeding, the nurse should check for tube placement in the stomach as well as residual volume. What is the purpose of the nurse's actions? A) Prevent gastric ulcers B) Prevent aspiration C) Prevent abdominal distention D) Prevent diarrhea
Failure to pass a meconium stool in the first 24 hours after birth, along with abdominal distention, are often the first signs of:
a. Meckel diverticulum. b. cystic fibrosis. c. biliary atresia. d. hydramnios.
In which of the following situations is it protocol for the nurse to take a patient's vital signs? Select all that apply
A) upon admitting a patient to a hospital B) at a healthcare screening C) when medications are given for a cardiac arrhythmia D) following a diagnostic procedure E) prior to an invasive procedure F) when daily medications are dispensed