Samuel merrit University, hesi med surg
Samuel merrit University, hesi med surg ( 45 Questions)
After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.
At checking the restraints, which action is most important for the nurse to take?
Choice A, reinserting the peripheral IV catheter, may be necessary but is not the most important action in this situation.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.