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 ["A","B","D"]

Explanation

A. 1 tbsp honey: Honey is a quick source of glucose and is an appropriate choice to raise blood sugar rapidly during hypoglycemia.

B. 5 hard candies: Hard candies containing sugar can provide a quick source of glucose and are suitable for treating hypoglycemia.

C. 240 mL regular sodamight provide 20 to 30 grams of carbohydrates, which could be too much and may lead to a rebound hypoglycemia after the initial correction of blood glucose levels.

D. 120 mL unsweetened fruit juice: Unsweetened fruit juice provides a quick source of glucose, which is essential for rapidly raising blood sugar levels in a hypoglycemic patient. The sugar in the juice is readily absorbed into the bloodstream, helping to counteract the effects of low blood sugar. It's important to choose unsweetened juice to avoid a sudden spike in blood sugar followed by another drop.

E. 120 mL milk: Milk contains lactose, a natural sugar, but it also contains protein and fat, which can slow down the absorption of sugar into the bloodstream. Therefore, it may not be as effective in rapidly raising blood sugar levels during an episode of hypoglycemia.

A. Choose orange juice instead of apple juice. B. Replace sugar with molasses when baking. C. Avoid using salt substitutes when cooking. D. Eat granola for breakfast.

Correct Answer is C

Explanation

A. Choose orange juice instead of apple juice:
Explanation: Orange juice is a source of potassium, so this choice would not be appropriate for a low potassium diet.

B. Replace sugar with molasses when baking:
Explanation: Molasses is a good alternative to sugar and does not contribute significantly to potassium intake, making it suitable for a low potassium diet.

C. Avoid using salt substitutes when cooking:
Explanation: Salt substitutes often contain potassium chloride, which can increase potassium intake. Therefore, it's advisable to avoid them on a low potassium diet.

D. Eat granola for breakfast:
Explanation: Granola can be a good source of potassium, so it may not be suitable for someone on a low potassium diet.

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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

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Explanation

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