Author Question: The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to ... (Read 22 times)

dollx · **on:** Jul 22, 2018

The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint?

a. The patient refuses to call for help to go to the bathroom.
b. The patient continues to remove the nasogastric tube.
c. The patient gets confused regarding the time at night.
d. The patient does not sleep and continues to ask for items.

Question 2

The female client is on the surgical unit and being readied for abdominal surgery with general anaesthesia early in the afternoon. Which of the following actions should the nurse take in pre-paring this client for surgery?

a. Leave all of her jewellery intact.
b. Provide her with sips of water for a dry mouth.
c. Remove her makeup and nail polish.
d. Remove her hearing aid before transport to the operating room.

Dominic · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

Answer to Question 2

C
All makeup, including nail polish, should be removed to expose normal skin and nail colour to determine the client's level of oxygenation and circulation during and after surgery.
Jewellery and other valuables should be given to family members or secured for safekeeping. A wedding band can be taped in place unless the client might experience swelling of the hand or fingers. For safety, metal items, such as in pierced areas, should be removed.
The client should be NPO (nothing by mouth) before surgery to prevent vomiting and aspiration with general anaesthesia.
Clients may be allowed to keep personal items such as a hearing aid until they reach the preoper-ative area.