Answer to Question 1
A
When restraints are necessary, the nurse should institute the least restrictive type of restraint. Knots must be tied so that they can be easily undone for quick access to the child. The ties are never tied to the mattress or side rails. They should be secured to a stable device, such as the bed frame. Restraints are removed every 2 hours to allow for range of motion, position changes, and assessment of skin integrity.
Answer to Question 2
B
The pH of fluid aspirated from the stomach should be 5 or lower. This is the most reliable method for indicating that a nasogastric tube is properly placed. Intact swallowing, coughing, and gagging reflexes should not be used in the determination of nasogastric tube placement. Fluid aspirated from the stomach can have a grassy green, brown, or clear, mucoid-flecked appearance, but this is not the most reliable way to determine correct placement. A whooshing or gurgling sound can be heard as air injected into the tube enters the stomach, but this is not the most reliable method for determining tube placement.
The nurse applies a pulse oximeter sensor on the client’s finger.
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