A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

"I will cover the catheter so he cannot see it."

"Let me provide more stimulation in his environment."

"Let's wait until tonight to see if he continues this behavior."

"I will call the doctor and get the prescription."

Answer and Explanation

The Correct Answer is D

A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.

B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.

C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.

D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.

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Correct Answer is C

Explanation

A. Using the ball of the finger (the fleshy part) is not recommended as it can lead to more pain and discomfort. The side of the fingertip is generally preferred for less discomfort and more accurate results.

B. Avoids using the fingers of her dominant hand as puncture sites:While it's generally recommended to avoid using the fingers of your dominant hand for frequent blood glucose monitoring, it's not always necessary. The client can still obtain accurate readings from her dominant hand if she rotates puncture sites.

C. Using the side of the fingertip is a recommended practice. The side of the fingertip has fewer nerve endings than the pad of the finger, which helps reduce discomfort. This technique is commonly used for more accurate and less painful blood glucose testing.

D. Avoids using the thumbs as puncture sites:
Using thumbs as puncture sites is generally avoided because they might have thicker skin and could yield less accurate blood samples. Therefore, avoiding thumbs for blood glucose testing is a good practice.

A. Flush the tube with water. B. Measure stomach contents. C. Elevate the head of the bed. D. Return gastric content into the gastrostomy tube.

Correct Answer is A

Explanation

A. Flush the tube with water:
This is the correct action to take first. Flushing the tube with water ensures that the tube is clear and functional before administering the bolus enteral feeding.

B. Measure stomach contents:
This is not the first action to take. Before measuring stomach contents, it's important to confirm that the tube is patent and clear by flushing it with water.

C. Elevate the head of the bed:
While elevating the head of the bed is important during and after enteral feedings to reduce the risk of aspiration, it is not the first step. The initial focus should be on verifying the tube's patency.

D. Return gastric content into the gastrostomy tube:
If there is resistance or difficulty flushing the tube, returning gastric contents into the tube may be necessary, but it's not the first action. The first step is to attempt to clear the tube with water.

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A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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